Provider Demographics
NPI:1861427247
Name:LARA, DOMINGO A (MD)
Entity type:Individual
Prefix:DR
First Name:DOMINGO
Middle Name:A
Last Name:LARA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1303 MCCULLOUGH AVE
Mailing Address - Street 2:138
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-5609
Mailing Address - Country:US
Mailing Address - Phone:210-225-3330
Mailing Address - Fax:210-497-8189
Practice Address - Street 1:1303 MCCULLOUGH AVE
Practice Address - Street 2:138
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-5609
Practice Address - Country:US
Practice Address - Phone:210-225-3330
Practice Address - Fax:210-497-8189
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXG65502084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114716703Medicaid
TX00FG28Medicare PIN
TX114716703Medicaid