Provider Demographics
NPI:1588005904
Name:HATHOUT, LARA
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:HATHOUT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 LITTLE ALBANY ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-1914
Mailing Address - Country:US
Mailing Address - Phone:732-235-2465
Mailing Address - Fax:
Practice Address - Street 1:195 LITTLE ALBANY ST
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1914
Practice Address - Country:US
Practice Address - Phone:732-235-2465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-14
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA099107002085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology