Provider Demographics
NPI:1902784077
Name:LARA, DAMIAN
Entity type:Individual
Prefix:
First Name:DAMIAN
Middle Name:
Last Name:LARA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3724 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-6225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 FUCHSIA DR
Practice Address - Street 2:
Practice Address - City:FREEDOM
Practice Address - State:CA
Practice Address - Zip Code:95019-3127
Practice Address - Country:US
Practice Address - Phone:831-254-8387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-26
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86359774133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered