Provider Demographics
NPI:1558749390
Name:PAVAGEAU, LARA (MD)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:PAVAGEAU
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 1:3001 GEORGE BUSH HWY STE 225
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-3569
Mailing Address - Country:US
Mailing Address - Phone:214-343-6663
Mailing Address - Fax:214-343-2814
Practice Address - Street 1:3001 GEORGE BUSH HWY STE 225
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-3569
Practice Address - Country:US
Practice Address - Phone:214-343-6663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-13
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT0599208M00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX428205501Medicaid