Provider Demographics
NPI:1689604647
Name:BURBANO DE LARA, JOSE L (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:L
Last Name:BURBANO DE LARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 E HEBRON PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-4457
Mailing Address - Country:US
Mailing Address - Phone:972-492-2776
Mailing Address - Fax:972-492-8268
Practice Address - Street 1:3020 E HEBRON PKWY STE 100
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-4457
Practice Address - Country:US
Practice Address - Phone:972-492-2776
Practice Address - Fax:972-492-8268
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9254207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133783408Medicaid
TX133783403Medicaid
TX85985KMedicare ID - Type Unspecified
TX133783403Medicaid
TX133783408Medicaid