Basic Information
| Provider Information | |||||||||
| NPI: | 1194883546 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARA | ||||||||
| FirstName: | NATHALIE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 95 GRASSLANDS RD | ||||||||
| Address2: | |||||||||
| City: | VALHALLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105951652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149090225 | ||||||||
| FaxNumber: | 2035033254 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 COLUMBUS AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035033292 | ||||||||
| FaxNumber: | 2037810276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
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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 | 207R00000X | 044605 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | 2084P0800X | 044605 | CT | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 004235918 | 05 | CT | MEDICAID | 004235900 | 05 | CT | MEDICAID |