Provider Demographics
NPI:1760587125
Name:LASTARRIA, EMILIO (MD)
Entity Type:Individual
Prefix:
First Name:EMILIO
Middle Name:
Last Name:LASTARRIA
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 1:35 MASON ST
Mailing Address - Street 2:SUITE 214
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-1133
Mailing Address - Country:US
Mailing Address - Phone:315-230-5646
Mailing Address - Fax:315-230-5645
Practice Address - Street 1:158 NORTH ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-1647
Practice Address - Country:US
Practice Address - Phone:315-719-0066
Practice Address - Fax:315-719-0373
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI74228208800000X
NY173332208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL271102800Medicaid
FLP00082844OtherRR MEDICARE
FLP00082844OtherRR MEDICARE
FL271102800Medicaid