Healthcare Provider Details

I. General information

NPI: 1992371389
Provider Name (Legal Business Name): LARA JAMAL-GHANDOUR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LARA EL JAMAL

II. Dates (important events)

Enumeration Date: 05/27/2021
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 MONROE ST UNIT 301
SYLVANIA OH
43560-2737
US

IV. Provider business mailing address

100 MADISON AVE
TOLEDO OH
43604-1516
US

V. Phone/Fax

Practice location:
  • Phone: 419-291-2121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.150190
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: