Provider Demographics
NPI:1982081543
Name:ALKHAWALDEH, LARA (MD)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:ALKHAWALDEH
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 1:1621 N SAYRE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60707-4322
Mailing Address - Country:US
Mailing Address - Phone:708-543-4519
Mailing Address - Fax:
Practice Address - Street 1:1621 N SAYRE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60707-4322
Practice Address - Country:US
Practice Address - Phone:708-543-4519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-04
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01079976A207Q00000X, 208M00000X
IL125067573390200000X
IL036144150208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300021101Medicaid