Provider Demographics
NPI:1821484361
Name:INDIA, LARA RENEE (MD)
Entity Type:Individual
Prefix:DR
First Name:LARA
Middle Name:RENEE
Last Name:INDIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LARA
Other - Middle Name:RENEE INDIA
Other - Last Name:ROSEWICZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-8700
Mailing Address - Fax:414-259-1522
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-8700
Practice Address - Fax:414-259-1522
Is Sole Proprietor?:No
Enumeration Date:2015-04-11
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI66231207LH0002X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LH0002XAllopathic & Osteopathic PhysiciansAnesthesiologyHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1821484361Medicaid