Basic Information
| Provider Information | |||||||||
| NPI: | 1881608040 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | LARA | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5865 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794085865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432898 | ||||||||
| FaxNumber: | 8067432787 | ||||||||
| Practice Location | |||||||||
| Address1: | 4015 22ND PL | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794101119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067256000 | ||||||||
| FaxNumber: | 8067237753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 12/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | M1801 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | 208M00000X | M1801 | TX | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 144240101 | 05 | TX | MEDICAID | 175706401 | 05 | TX | MEDICAID | 175706402 | 05 | TX | MEDICAID | 200059820A | 05 | OK | MEDICAID | 202000094 | 05 | NM | MEDICAID | 8S6820 | 01 | TX | HMO BLUE | OTHER | 202000094 | 01 | NM | PRESBYTERIAN COMMERCIAL | OTHER | 35808012 | 05 | NM | MEDICAID | 144240100 | 01 | TX | FIRSTCARE COMMERCIAL | OTHER | 8G6055 | 01 | TX | BC/BS | OTHER | 450686CI38448 | 01 | TX | SECTION 1011 | OTHER |