Healthcare Provider Details

I. General information

NPI: 1992809354
Provider Name (Legal Business Name): IONE VILDRIA LARA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: IONE VILDRIA LARA KOKSENG MD

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2212 E HENRY AVENUE
TAMPA FL
33610
US

IV. Provider business mailing address

2212 E HENRY AVENUE
TAMPA FL
33610
US

V. Phone/Fax

Practice location:
  • Phone: 813-272-2882
  • Fax: 813-272-3198
Mailing address:
  • Phone: 813-272-2882
  • Fax: 813-272-3198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberME41287
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: