Provider Demographics
NPI:1093806382
Name:LAZAR, SHELLEE RAE (MD)
Entity Type:Individual
Prefix:DR
First Name:SHELLEE
Middle Name:RAE
Last Name:LAZAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHELLEE
Other - Middle Name:RAE
Other - Last Name:MIYASATO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4240 HIGHLAND AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:HIGHLAND
Mailing Address - State:CA
Mailing Address - Zip Code:92346-2764
Mailing Address - Country:US
Mailing Address - Phone:909-864-4700
Mailing Address - Fax:909-864-4300
Practice Address - Street 1:4240 HIGHLAND AVE
Practice Address - Street 2:SUITE B
Practice Address - City:HIGHLAND
Practice Address - State:CA
Practice Address - Zip Code:92346-2764
Practice Address - Country:US
Practice Address - Phone:909-864-4700
Practice Address - Fax:909-864-4300
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66921207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A669210Medicaid
CA1467402149Medicaid
CA1467402149Medicaid