Provider Demographics
NPI:1376575910
Name:LARA, OLEGARIO JAY (DO)
Entity Type:Individual
Prefix:
First Name:OLEGARIO
Middle Name:JAY
Last Name:LARA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 LAWRENCE EXPY
Mailing Address - Street 2:DEPT. 396
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95051-5173
Mailing Address - Country:US
Mailing Address - Phone:408-851-5067
Mailing Address - Fax:
Practice Address - Street 1:710 LAWRENCE EXPY
Practice Address - Street 2:DEPT. 396
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95051-5173
Practice Address - Country:US
Practice Address - Phone:408-851-5067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A66712085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX66710OtherMEDICAL
CAW20A66710BMedicare ID - Type Unspecified
CAG23654Medicare UPIN
CA00AX66710OtherMEDICAL