Provider Demographics
NPI:1811495492
Name:LARA REYNA, JACQUES JOSE (MD)
Entity type:Individual
Prefix:
First Name:JACQUES
Middle Name:JOSE
Last Name:LARA REYNA
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 1:614 W 157TH ST APT SE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032
Mailing Address - Country:US
Mailing Address - Phone:917-544-5136
Mailing Address - Fax:
Practice Address - Street 1:1000 10TH AVENUE - MOUNT SINAI WEST
Practice Address - Street 2:SUITE 5G - 80 DEPARTMENT OF NEUROSURGERY
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029
Practice Address - Country:US
Practice Address - Phone:212-363-3784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2018-09-20
Deactivation Date:2018-09-07
Deactivation Code:
Reactivation Date:2018-09-20
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program