Provider Demographics
NPI:1194909481
Name:LARA, FIDEL M JR (MD)
Entity type:Individual
Prefix:DR
First Name:FIDEL
Middle Name:M
Last Name:LARA
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:8033 VINELAND AVENUE
Mailing Address - Street 2:LARA MEDICAL CLINIC
Mailing Address - City:SUN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91352-3951
Mailing Address - Country:US
Mailing Address - Phone:818-767-1001
Mailing Address - Fax:818-767-1991
Practice Address - Street 1:8033 VINELAND AVENUE
Practice Address - Street 2:LARA MEDICAL CLINIC
Practice Address - City:SUN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91352-3951
Practice Address - Country:US
Practice Address - Phone:818-767-1001
Practice Address - Fax:818-767-1991
Is Sole Proprietor?:No
Enumeration Date:2007-12-21
Last Update Date:2008-11-17
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Provider Licenses
StateLicense IDTaxonomies
CAA69653207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA696530Medicaid
CAWA69653AMedicare PIN
CAA696530Medicaid