Provider Demographics
NPI:1962457465
Name:HITCHCOCK, LARA DAVIS (MD)
Entity Type:Individual
Prefix:DR
First Name:LARA
Middle Name:DAVIS
Last Name:HITCHCOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HITCHCOCK
Other - Middle Name:HEALTH
Other - Last Name:INSTITUTE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:7932 W SAND LAKE RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-7263
Mailing Address - Country:US
Mailing Address - Phone:407-578-3303
Mailing Address - Fax:407-578-9144
Practice Address - Street 1:7932 W SAND LAKE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-7263
Practice Address - Country:US
Practice Address - Phone:407-578-3303
Practice Address - Fax:407-578-9144
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME79029207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH20157Medicare UPIN