Basic Information
| Provider Information | |||||||||
| NPI: | 1073501235 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PESAVENTO | ||||||||
| FirstName: | LARA | ||||||||
| MiddleName: | JANE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7232 | ||||||||
| Address2: | DEPT 118 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462077232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175672180 | ||||||||
| FaxNumber: | 3176149655 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 N SENATE BLVD | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462021239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175672180 | ||||||||
| FaxNumber: | 3176149655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 07/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 01061430 | IN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 200849010 | 05 | IN | MEDICAID |