Provider Demographics
NPI:1578639621
Name:LARA, SERGIO ANDRES (MD)
Entity Type:Individual
Prefix:DR
First Name:SERGIO
Middle Name:ANDRES
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 1:2606 YONKERS ST
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:79072-1851
Mailing Address - Country:US
Mailing Address - Phone:806-291-5121
Mailing Address - Fax:806-291-5122
Practice Address - Street 1:2606 YONKERS ST
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:TX
Practice Address - Zip Code:79072-1851
Practice Address - Country:US
Practice Address - Phone:806-291-5121
Practice Address - Fax:806-291-5122
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3371207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1205070398OtherNPI FOR GROUP PRACTICE
TX169966204Medicaid
I20219Medicare UPIN
TX8F21193Medicare PIN