Provider Demographics
NPI:1083619431
Name:LAZAROVICH, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:LAZAROVICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 TIMBER LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-5201
Mailing Address - Country:US
Mailing Address - Phone:802-864-0294
Mailing Address - Fax:802-864-3779
Practice Address - Street 1:53 TIMBER LN
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-5201
Practice Address - Country:US
Practice Address - Phone:802-864-0294
Practice Address - Fax:802-864-3779
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT18970OtherBLUE CROSS BLUE SHIELD VT
NY92Q141OtherBCBS NORTHEAST NEW YORK
VT0VN0712Medicaid
VT0176890-002OtherCIGNA
NY02106825Medicaid
VT03V005OtherMVP
VT18970OtherBLUE CROSS BLUE SHIELD VT
NY92Q141OtherBCBS NORTHEAST NEW YORK