Provider Demographics
NPI:1043280449
Name:CHURCH, LARA DIANE (MD)
Entity type:Individual
Prefix:DR
First Name:LARA
Middle Name:DIANE
Last Name:CHURCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 45443
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84145-0443
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:141 HILDEN RD STE 201
Practice Address - Street 2:CREDENTIALING DEPARTMENT
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-8400
Practice Address - Country:US
Practice Address - Phone:904-825-1941
Practice Address - Fax:904-829-2850
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2018-12-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME105548207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01431326OtherRR MEDICARE
FLFU422ZMedicare PIN