MEDICARE: DR. MARIE-ALICE LARA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	ME79139	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	35540	OTHER	FL	BLUE CROSS BLUE SHIELD
2	1722315001	OTHER	FL	CIGNA
3	274662	OTHER	FL	WELLCARE
4	7477630	OTHER	FL	AETNA
5	2039274	OTHER	FL	UNITED HEALTH CARE
6	295786	OTHER	FL	AV-MED
7	170211	OTHER	FL	HUMANA

General Provider Information

NPI Number	:	1851386684
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIE-ALICE LARA M.D.

Provider Business Mailing Address
First Line	:	PO BOX 848127
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33084-0127
Country	:	US
Telephone Number	:	954-517-9166
Fax Number	:	954-517-9167

Provider Business Practice Location Address
First Line	:	10000 STIRLING RD
Second Line	:	SUITE 3
City	:	COOPER CITY
State	:	FL
Zip	:	33024-8067
Country	:	US
Telephone Number	:	954-517-9166
Fax Number	:	954-517-9167

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2005
Last Update Date	:	04/02/2008

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Directions to “ DR. MARIE-ALICE LARA M.D.” Practice Location

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