MEDICARE: TERESITA C DE 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	207RE0101X	Endocrinology, Diabetes & Metabolism Physician	ME35368	FL

General Provider Information

NPI Number	:	1891725677
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERESITA C DE LARA M.D.

Provider Business Mailing Address
First Line	:	2400 HARBOR BLVD STE 3
Second Line	:
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33952-5038
Country	:	US
Telephone Number	:	941-629-1288
Fax Number	:	941-625-0570

Provider Business Practice Location Address
First Line	:	2400 HARBOR BLVD STE 3
Second Line	:
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33952-5038
Country	:	US
Telephone Number	:	941-629-1288
Fax Number	:	941-625-0570

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

Provider Enumeration Date	:	07/04/2006
Last Update Date	:	08/07/2017

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