Provider Demographics
NPI:1205354883
Name:LARA, JULIAN (COA)
Entity type:Individual
Prefix:
First Name:JULIAN
Middle Name:
Last Name:LARA
Suffix:
Gender:M
Credentials:COA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9813 S KEELER AVE APT D
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-3474
Mailing Address - Country:US
Mailing Address - Phone:773-290-4157
Mailing Address - Fax:
Practice Address - Street 1:550 E BOUGHTON RD STE 120
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-2193
Practice Address - Country:US
Practice Address - Phone:630-783-9960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1101XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic Assistant