Provider Demographics
NPI:1578883542
Name:LARA, JOSE FELIX (PT)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:FELIX
Last Name:LARA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 WINTER ST
Mailing Address - Street 2:
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640-5496
Mailing Address - Country:US
Mailing Address - Phone:512-262-7304
Mailing Address - Fax:
Practice Address - Street 1:1900 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7520
Practice Address - Country:US
Practice Address - Phone:512-396-1888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-01
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1173059225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7735Medicaid