Provider Demographics
NPI:1477048080
Name:RYBAK, LARA RAE (MD)
Entity Type:Individual
Prefix:DR
First Name:LARA
Middle Name:RAE
Last Name:RYBAK
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 1:5416 SW 97TH TER
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-4347
Mailing Address - Country:US
Mailing Address - Phone:352-665-9961
Mailing Address - Fax:
Practice Address - Street 1:410 NE WALDO RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32641
Practice Address - Country:US
Practice Address - Phone:352-265-7015
Practice Address - Fax:352-265-7021
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME135487207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100445500Medicaid