Provider Demographics
NPI:1992853790
Name:LARA, JAIME F (MD)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:F
Last Name:LARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 STANWORTH ROAD
Mailing Address - Street 2:
Mailing Address - City:KENDALL PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08824
Mailing Address - Country:US
Mailing Address - Phone:732-940-0505
Mailing Address - Fax:732-940-1997
Practice Address - Street 1:3 STANWORTH ROAD
Practice Address - Street 2:
Practice Address - City:KENDALL PARK
Practice Address - State:NJ
Practice Address - Zip Code:08824
Practice Address - Country:US
Practice Address - Phone:732-940-0505
Practice Address - Fax:732-940-1997
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04235300207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A60154Medicare UPIN
476302Medicare ID - Type Unspecified