Provider Demographics
NPI:1134166978
Name:LARA, REGINA A (MD)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:A
Last Name:LARA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1882
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10009-8911
Mailing Address - Country:US
Mailing Address - Phone:212-228-6406
Mailing Address - Fax:
Practice Address - Street 1:669 CASTLETON AVE
Practice Address - Street 2:STATEN ISLAND MENTAL HEALTH SOCIETY
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301
Practice Address - Country:US
Practice Address - Phone:718-442-2225
Practice Address - Fax:718-442-2289
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2140592084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH29365Medicare UPIN
NY001R21Medicare ID - Type Unspecified