Provider Demographics
NPI:1902241425
Name:ILYAS, LARA SHAHAR (MD)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:SHAHAR
Last Name:ILYAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 COMMERCE PLZ
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:ME
Mailing Address - Zip Code:04364-1498
Mailing Address - Country:US
Mailing Address - Phone:207-624-3800
Mailing Address - Fax:207-624-3845
Practice Address - Street 1:16 COMMERCE PLZ
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:ME
Practice Address - Zip Code:04364-1498
Practice Address - Country:US
Practice Address - Phone:207-624-3800
Practice Address - Fax:207-624-3845
Is Sole Proprietor?:No
Enumeration Date:2013-05-10
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MEMD22023207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program