1104094739 NPI number — DR. MARK GREGORY LAZAREV M.D.

Table of content: DR. MARK GREGORY LAZAREV M.D. (NPI 1104094739)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104094739 NPI number — DR. MARK GREGORY LAZAREV M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAZAREV
Provider First Name:
MARK
Provider Middle Name:
GREGORY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104094739
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 64264
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21264-4264
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 N WOLFE ST
Provider Second Line Business Practice Location Address:
1830 BLDG, RM 420
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21287-0006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-614-6708
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/17/2008

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: 207RG0100X , with the licence number:  MT185907 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: D69337 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 418086100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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