Provider Demographics
NPI:1407907553
Name:FORD, LARA (MD)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 DEXTER AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-4230
Mailing Address - Country:US
Mailing Address - Phone:857-389-6724
Mailing Address - Fax:
Practice Address - Street 1:281 LINCOLN ST
Practice Address - Street 2:MEDICAL STAFF SVCS
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2138
Practice Address - Country:US
Practice Address - Phone:508-334-8015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA222427208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics