Healthcare Provider Details

I. General information

NPI: 1205455193
Provider Name (Legal Business Name): LARA E GAGLIARDI DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2020
Last Update Date: 07/21/2023
Certification Date: 07/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 KEMPSVILLE RD BLDG B
NORFOLK VA
23502-4732
US

IV. Provider business mailing address

5020 FINN RD
VIRGINIA BEACH VA
23455-2620
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-6500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0102207796
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: