Provider Demographics
NPI:1598721490
Name:LARA, MICHAEL DAVID (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
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 1:1655 MOSSWOOD
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79935-3435
Mailing Address - Country:US
Mailing Address - Phone:915-591-7700
Mailing Address - Fax:915-591-3170
Practice Address - Street 1:1655 MOSSWOOD
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79935-3435
Practice Address - Country:US
Practice Address - Phone:915-591-7700
Practice Address - Fax:915-591-3170
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8406208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX168612301Medicaid
TX8C8471Medicare PIN
TX168612301Medicaid