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General NPI Number Information
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NPI Number | 1457353054
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Entity Type | Individual
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Provider Name | TIRSO MARK LARA M.D.
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Gender | Male
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Dates
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Enumeration Date | 08/12/2005
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Last Update Date | 03/22/2021
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Provider Practice Location Address
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Address Line | 850 S. PINE ISLAND RD. STE. A100
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City | PLANTATION
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State | FL
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Zip | 33351-6741
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Country | US
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Telephone | 954-741-5555
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Fax | 954-741-6298
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Provider Business Mailing Address
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Address Line | PO BOX 31796
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City | TAMPA
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State | FL
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Zip | 33631-3796
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Country | US
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Telephone | 954-851-9966
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Fax | 954-318-7360
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | ME93684
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License Number State | FL
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