Provider Demographics
NPI:1679889042
Name:AL-EJEILAT, LARA HAYEL (MD)
Entity Type:Individual
Prefix:DR
First Name:LARA
Middle Name:HAYEL
Last Name:AL-EJEILAT
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 1:5103 LINCOLN DR
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55436-1009
Mailing Address - Country:US
Mailing Address - Phone:352-871-1592
Mailing Address - Fax:
Practice Address - Street 1:14500 99TH AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4730
Practice Address - Country:US
Practice Address - Phone:763-898-1000
Practice Address - Fax:763-898-1009
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN56470208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics