Provider Demographics
NPI:1356444780
Name:PRIMAK, LARA KRISTINA (MD)
Entity Type:Individual
Prefix:DR
First Name:LARA
Middle Name:KRISTINA
Last Name:PRIMAK
Suffix:
Gender:F
Credentials:MD
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11050 MT. BELVEDERE BLVD.
Mailing Address - Street 2:USA MEDDAC ATTN: CREDENTIALS
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-5004
Mailing Address - Country:US
Mailing Address - Phone:315-772-4025
Mailing Address - Fax:315-772-9498
Practice Address - Street 1:11050 MT. BELVEDERE BLVD.
Practice Address - Street 2:USA MEDDAC/CREDENTIALS
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5004
Practice Address - Country:US
Practice Address - Phone:315-772-4025
Practice Address - Fax:315-772-9498
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD063446L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN