Healthcare Provider Details

I. General information

NPI: 1013338755
Provider Name (Legal Business Name): GREGORY G LARA MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2013
Last Update Date: 12/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 S CENTRAL AVE
GLENDALE CA
91204-2508
US

IV. Provider business mailing address

PO BOX 60790
PASADENA CA
91116-6790
US

V. Phone/Fax

Practice location:
  • Phone: 818-502-1900
  • Fax:
Mailing address:
  • Phone: 626-204-6747
  • Fax: 626-396-0851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA69087
License Number StateCA

VIII. Authorized Official

Name: DR. GREGORY G LARA
Title or Position: PRESIDENT
Credential: MD
Phone: 310-991-0190