Provider Demographics
NPI:1083709299
Name:LAZORE-MACK, LESLIE MARIE (DO)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:MARIE
Last Name:LAZORE-MACK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1903 MORGANTOWN RD
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19607
Mailing Address - Country:US
Mailing Address - Phone:610-777-4040
Mailing Address - Fax:610-777-5575
Practice Address - Street 1:1903 MORGANTOWN RD
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19607
Practice Address - Country:US
Practice Address - Phone:610-777-4040
Practice Address - Fax:610-777-5575
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012389207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAO79906Medicare UPIN
PA079906MZPMedicare ID - Type Unspecified
PAI08099Medicare UPIN