1376505180 NPI number — MICHAEL J LAZAR JR. MD

Table of content: MICHAEL J LAZAR JR. MD (NPI 1376505180)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376505180 NPI number — MICHAEL J LAZAR JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAZAR
Provider First Name:
MICHAEL
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
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:
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:
1376505180
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3536 MENDOCINO AVE
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
SANTA ROSA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95403-3634
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-575-6049
Provider Business Mailing Address Fax Number:
707-546-0725

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1140 SONOMA AVE
Provider Second Line Business Practice Location Address:
STE 1A
Provider Business Practice Location Address City Name:
SANTA ROSA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95405-4817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-546-5553
Provider Business Practice Location Address Fax Number:
707-546-0725
Provider Enumeration Date:
04/05/2006

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: 208800000X , with the licence number:  C40958 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2088P0231X , with the licence number: C40958 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: P00638732 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1376505180 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00C409580 . This is a "BS OF CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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