Provider Demographics
NPI:1063605913
Name:WILFREDO CONSTANTINO LARA MD PLLC
Entity type:Organization
Organization Name:WILFREDO CONSTANTINO LARA MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILFREDO
Authorized Official - Middle Name:CONSTANTINO
Authorized Official - Last Name:LARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-643-8871
Mailing Address - Street 1:PO BOX 144336
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33114-4336
Mailing Address - Country:US
Mailing Address - Phone:305-643-8871
Mailing Address - Fax:305-643-8872
Practice Address - Street 1:351 NW 42ND AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-5683
Practice Address - Country:US
Practice Address - Phone:305-643-8871
Practice Address - Fax:305-643-8872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-23
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL446289OtherMEDICA HEALTHCARE
FL8796542OtherCIGNA
FLAF467Medicare PIN