Provider Demographics
NPI:1336186337
Name:LARA, WILLIAM KEITH (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:KEITH
Last Name:LARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KEITH
Other - Middle Name:
Other - Last Name:LARA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:202 CONWAY DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3112
Mailing Address - Country:US
Mailing Address - Phone:406-752-5656
Mailing Address - Fax:406-755-0971
Practice Address - Street 1:310 SUNNYVIEW LN
Practice Address - Street 2:EMERGENCY DEPT
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3129
Practice Address - Country:US
Practice Address - Phone:406-752-1708
Practice Address - Fax:406-755-0971
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT7809207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT152677Medicaid
MT93206OtherBLUE CROSS
MT152677Medicaid