Provider Demographics
NPI:1801935622
Name:LARA, JOSE MILTON (MD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:MILTON
Last Name:LARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4670 GAGE AVE
Mailing Address - Street 2:
Mailing Address - City:BELL
Mailing Address - State:CA
Mailing Address - Zip Code:90201-1360
Mailing Address - Country:US
Mailing Address - Phone:323-562-3135
Mailing Address - Fax:323-973-2553
Practice Address - Street 1:4670 GAGE AVE
Practice Address - Street 2:
Practice Address - City:BELL
Practice Address - State:CA
Practice Address - Zip Code:90201-1360
Practice Address - Country:US
Practice Address - Phone:323-562-3135
Practice Address - Fax:323-973-2553
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A51277207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A51277OtherMEDICARE NUMBER
CA00A512770Medicaid
CA00A512770Medicaid