Provider Demographics
NPI:1457353054
Name:LARA, TIRSO MARK (MD)
Entity type:Individual
Prefix:DR
First Name:TIRSO
Middle Name:MARK
Last Name:LARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 31796
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33631-3796
Mailing Address - Country:US
Mailing Address - Phone:954-851-9966
Mailing Address - Fax:954-318-7360
Practice Address - Street 1:850 S. PINE ISLAND RD.
Practice Address - Street 2:STE. A100
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33351-6741
Practice Address - Country:US
Practice Address - Phone:954-741-5555
Practice Address - Fax:954-741-6298
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME93684207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7799557OtherAETNA
FL28741OtherBLUE CROSS BLUE SHEILD
FL301162OtherAVMED
FL650560968OtherUNITED
FL273396000Medicaid
FL301162OtherCOMPBENEFITS CORPORATION
FL650560968OtherCIGNA
FL650560968OtherHUMANA
FL28741ZMedicare PIN
H81607Medicare UPIN
FL650560968OtherCIGNA
FL273396000Medicaid