1699088104 NPI number — LAZAU P FOUGERE MD

Table of content: LAZAU P FOUGERE MD (NPI 1699088104)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699088104 NPI number — LAZAU P FOUGERE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FOUGERE
Provider First Name:
LAZAU
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FOUGERE
Provider Other First Name:
LAZAU
Provider Other Middle Name:
P
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1699088104
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/22/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
507 W ALEXANDER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLANT CITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33563-7136
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-754-3504
Provider Business Mailing Address Fax Number:
813-752-6863

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5503 E BUSCH BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEMPLE TERRACE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33617-5419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-200-7717
Provider Business Practice Location Address Fax Number:
813-985-8500
Provider Enumeration Date:
07/26/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME122282 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)