Provider Demographics
NPI:1316982713
Name:LARA, MARIA ELENA (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:ELENA
Last Name:LARA
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 MAIN STREET
Mailing Address - Street 2:RAND
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90407
Mailing Address - Country:US
Mailing Address - Phone:310-393-0411
Mailing Address - Fax:310-260-8175
Practice Address - Street 1:1776 MAIN STREET
Practice Address - Street 2:RAND
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90407
Practice Address - Country:US
Practice Address - Phone:310-393-0411
Practice Address - Fax:310-260-8175
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG072582208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0053510Medicaid
CA00G725820Medicaid
CAG72582Medicare UPIN
CAW11810Medicare ID - Type UnspecifiedGROUP NUMBER
CAGR0053510Medicaid