Provider Demographics
NPI:1124440227
Name:MIRIAM M. LARA M.D. PA
Entity type:Organization
Organization Name:MIRIAM M. LARA M.D. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:MERCEDES
Authorized Official - Last Name:LARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-362-3969
Mailing Address - Street 1:2100 W 68TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-1804
Mailing Address - Country:US
Mailing Address - Phone:305-362-3969
Mailing Address - Fax:305-362-7909
Practice Address - Street 1:2100 W 68TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-1804
Practice Address - Country:US
Practice Address - Phone:305-362-3969
Practice Address - Fax:305-362-7909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-09
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0047182305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL035062100Medicaid
FL96848CMedicare Oscar/Certification
D64009Medicare UPIN