Provider Demographics
NPI:1508924788
Name:LARA MEDICAL CORPORATION
Entity Type:Organization
Organization Name:LARA MEDICAL CORPORATION
Other - Org Name:LARA MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:FIDEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:LARA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:818-767-1001
Mailing Address - Street 1:8033 VINELAND AVENUE
Mailing Address - Street 2:ATTN FIDEL M. LARA JR MD
Mailing Address - City:SUN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91352-3951
Mailing Address - Country:US
Mailing Address - Phone:818-767-1001
Mailing Address - Fax:818-767-1991
Practice Address - Street 1:8033 VINELAND AVENUE
Practice Address - Street 2:ATTN FIDEL M. LARA JR MD
Practice Address - City:SUN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91352-3951
Practice Address - Country:US
Practice Address - Phone:818-767-1001
Practice Address - Fax:818-767-1991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA696530207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA696530Medicaid
CAW18293Medicare ID - Type Unspecified
CAA696530Medicaid