Provider Demographics
NPI:1306833405
Name:LAZINGER, MAXWELL (MD)
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:
Last Name:LAZINGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-5844
Mailing Address - Country:US
Mailing Address - Phone:573-815-3221
Mailing Address - Fax:573-815-6343
Practice Address - Street 1:1600 E BROADWAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-5844
Practice Address - Country:US
Practice Address - Phone:573-815-3221
Practice Address - Fax:573-815-6343
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20020076872085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205811201Medicaid
MO014010303Medicare PIN
MO205811201Medicaid