Basic Information
| Provider Information | |||||||||
| NPI: | 1154594679 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HART | ||||||||
| FirstName: | LARA | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 NORTHSIDE FORSYTH DR | ||||||||
| Address2: | STE. 260 | ||||||||
| City: | CUMMING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300418447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702552555 | ||||||||
| FaxNumber: | 7708890111 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 NORTHSIDE FORSYTH DR | ||||||||
| Address2: | STE. 260 | ||||||||
| City: | CUMMING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300418447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702552555 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2008 | ||||||||
| LastUpdateDate: | 05/11/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 67638 | GA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 003123182B | 05 | GA | MEDICAID |