MEDICARE: DR. LARA JAMAL-GHANDOUR MD

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	35.150190	OH

General Provider Information

NPI Number	:	1992371389
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARA JAMAL-GHANDOUR MD

Provider Business Mailing Address
First Line	:	100 MADISON AVE
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43604-1516
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5700 MONROE ST UNIT 301
Second Line	:
City	:	SYLVANIA
State	:	OH
Zip	:	43560-2737
Country	:	US
Telephone Number	:	419-291-2121
Fax Number	:

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

Provider Enumeration Date	:	05/27/2021
Last Update Date	:	08/12/2024

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