Provider Demographics
NPI:1992809354
Name:LARA, IONE VILDRIA (MD)
Entity type:Individual
Prefix:DR
First Name:IONE
Middle Name:VILDRIA
Last Name:LARA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:IONE
Other - Middle Name:VILDRIA
Other - Last Name:LARA KOKSENG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2212 E HENRY AVENUE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610
Mailing Address - Country:US
Mailing Address - Phone:813-272-2882
Mailing Address - Fax:813-272-3198
Practice Address - Street 1:2212 E HENRY AVENUE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610
Practice Address - Country:US
Practice Address - Phone:813-272-2882
Practice Address - Fax:813-272-3198
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME412872084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL30574OtherBCBS OF FL
D54045Medicare UPIN
FL305742Medicare ID - Type Unspecified