1629262126 NPI number — MARCELA A LAZO M.D.

Table of content: MARCELA A LAZO M.D. (NPI 1629262126)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629262126 NPI number — MARCELA A LAZO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAZO
Provider First Name:
MARCELA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1629262126
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 25317
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33622-5317
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-286-0033
Provider Business Mailing Address Fax Number:
813-282-1806

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4671 S CONGRESS AVE
Provider Second Line Business Practice Location Address:
SUITE 100B
Provider Business Practice Location Address City Name:
LAKE WORTH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33461-4783
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-434-0111
Provider Business Practice Location Address Fax Number:
561-296-3533
Provider Enumeration Date:
08/28/2007

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: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: ME110131 , 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)

  • Identifier: LN461 . This is a "MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 14FW0 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 004197300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 111141500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com