Provider Demographics
NPI:1699740324
Name:MANRIQUE DE LARA, CARLOS (MD, FACS)
Entity type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:
Last Name:MANRIQUE DE LARA
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2706
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78502-2706
Mailing Address - Country:US
Mailing Address - Phone:956-661-9000
Mailing Address - Fax:956-686-7833
Practice Address - Street 1:2518 W TRENTON RD
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-8070
Practice Address - Country:US
Practice Address - Phone:956-661-9000
Practice Address - Fax:956-686-7833
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3794207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX096608703Medicaid
TXF68146Medicare UPIN
TX096608703Medicaid