Provider Demographics
NPI:1477559417
Name:STEWART, LARA E (DO)
Entity Type:Individual
Prefix:DR
First Name:LARA
Middle Name:E
Last Name:STEWART
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:LARA
Other - Middle Name:E
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:2825 SANTA MONICA BLVD
Mailing Address - Street 2:STE 301
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2429
Mailing Address - Country:US
Mailing Address - Phone:310-829-3130
Mailing Address - Fax:310-828-9156
Practice Address - Street 1:2825 SANTA MONICA BLVD
Practice Address - Street 2:STE 301
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2429
Practice Address - Country:US
Practice Address - Phone:310-829-3130
Practice Address - Fax:310-828-9156
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003001210207Q00000X
CA20A9455207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO206087801Medicaid
MO206087801Medicaid
065010422Medicare ID - Type Unspecified