Provider Demographics
NPI:1437295482
Name:LARA, ROLANDO A (MD)
Entity Type:Individual
Prefix:
First Name:ROLANDO
Middle Name:A
Last Name:LARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1708 W 47TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60609
Mailing Address - Country:US
Mailing Address - Phone:773-927-9774
Mailing Address - Fax:773-927-0333
Practice Address - Street 1:1708 W 47TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609
Practice Address - Country:US
Practice Address - Phone:773-927-9774
Practice Address - Fax:773-927-0333
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
21604409OtherBLUE CROSS
D12677Medicare UPIN
21604409OtherBLUE CROSS