Provider Demographics
NPI:1154594679
Name:HART, LARA RENEE (MD)
Entity type:Individual
Prefix:DR
First Name:LARA
Middle Name:RENEE
Last Name:HART
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 NORTHSIDE FORSYTH DR
Mailing Address - Street 2:STE. 260
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-8447
Mailing Address - Country:US
Mailing Address - Phone:770-255-2555
Mailing Address - Fax:770-889-0111
Practice Address - Street 1:1800 NORTHSIDE FORSYTH DR
Practice Address - Street 2:STE. 260
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-8447
Practice Address - Country:US
Practice Address - Phone:770-255-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-04
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA67638207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003123182BMedicaid
GA202I162528Medicare PIN