Provider Demographics
NPI:1730110081
Name:LASTRA, JUAN (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:LASTRA
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 1:3723 EDENBORN AVE
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-1519
Mailing Address - Country:US
Mailing Address - Phone:504-400-3723
Mailing Address - Fax:504-885-1436
Practice Address - Street 1:3723 EDENBORN AVE
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-1519
Practice Address - Country:US
Practice Address - Phone:504-400-3723
Practice Address - Fax:504-885-1436
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA016506207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1354805Medicaid
LAB62626Medicare UPIN
LA1354805Medicaid