Provider Demographics
NPI:1760816367
Name:JOSE LARES-GUIA PHYSICIAN PC
Entity Type:Organization
Organization Name:JOSE LARES-GUIA PHYSICIAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:M
Authorized Official - Last Name:LARES-GUIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-613-6030
Mailing Address - Street 1:84 GROVE ST APT 3
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014-3566
Mailing Address - Country:US
Mailing Address - Phone:646-429-9555
Mailing Address - Fax:646-429-9555
Practice Address - Street 1:84 GROVE ST APT 3
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10014-3566
Practice Address - Country:US
Practice Address - Phone:646-429-5555
Practice Address - Fax:678-553-1274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-30
Last Update Date:2024-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03161662Medicaid