Provider Demographics
NPI:1245307941
Name:WITTINE, LARA M (MD)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:M
Last Name:WITTINE
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:13067 N TELECOM PKWY
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0926
Mailing Address - Country:US
Mailing Address - Phone:813-779-6303
Mailing Address - Fax:786-868-0012
Practice Address - Street 1:3000 MEDICAL PARK DR STE 510
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-6602
Practice Address - Country:US
Practice Address - Phone:813-615-7725
Practice Address - Fax:813-615-7082
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2024-03-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME125433207RS0012X, 207RP1001X
IA36974207RC0200X, 207RS0012X
MN55836207RS0012X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPJWDLOtherBLUE CROSS BLUE SHIELD
FL018286300Medicaid