Provider Demographics
NPI:1265961114
Name:LARA, JEANETTE (DO)
Entity type:Individual
Prefix:DR
First Name:JEANETTE
Middle Name:
Last Name:LARA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 ANGELINA BLVD
Mailing Address - Street 2:
Mailing Address - City:CHAPARRAL
Mailing Address - State:NM
Mailing Address - Zip Code:88081-7558
Mailing Address - Country:US
Mailing Address - Phone:758-248-1005
Mailing Address - Fax:575-824-8101
Practice Address - Street 1:204 ANGELINA BLVD
Practice Address - Street 2:
Practice Address - City:CHAPARRAL
Practice Address - State:NM
Practice Address - Zip Code:88081-7558
Practice Address - Country:US
Practice Address - Phone:758-248-1005
Practice Address - Fax:575-824-8101
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-05
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR-25-2017207Q00000X
NMA-2410-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty