Provider Demographics
NPI:1942238522
Name:LARA, WILFREDO C (MD)
Entity Type:Individual
Prefix:
First Name:WILFREDO
Middle Name:C
Last Name:LARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:WILFREDO
Other - Middle Name:CONSTANTINO
Other - Last Name:LARA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 144336
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33114-4336
Mailing Address - Country:US
Mailing Address - Phone:305-643-8871
Mailing Address - Fax:305-643-8872
Practice Address - Street 1:351 NW 42ND AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-5683
Practice Address - Country:US
Practice Address - Phone:305-643-8871
Practice Address - Fax:305-643-8872
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86697207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269577407Medicaid
FL5730290OtherCIGNA
FL269577402Medicaid
FL269577408Medicaid
FL7403OtherMEDICA HEALTHCARE
FL269577405Medicaid
FL37551OtherBLUE CROSS BLUE SHIELD
FL2416244OtherUNITED HEALTHCARE
FL7192597OtherAETNA
FL269577406Medicaid
FL269577408Medicaid
FL269577407Medicaid