Provider Demographics
NPI:1437232022
Name:LARA, ETHELBERT M (MD)
Entity Type:Individual
Prefix:DR
First Name:ETHELBERT
Middle Name:M
Last Name:LARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:710 CHIPPEWA SQ
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-4821
Mailing Address - Country:US
Mailing Address - Phone:906-225-0122
Mailing Address - Fax:906-225-0135
Practice Address - Street 1:205 OSCEOLA ST
Practice Address - Street 2:
Practice Address - City:LAURIUM
Practice Address - State:MI
Practice Address - Zip Code:49913-2134
Practice Address - Country:US
Practice Address - Phone:906-225-0122
Practice Address - Fax:906-225-0135
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI43010394132085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4833513Medicaid
MIB44439Medicare UPIN
MI4833513Medicaid