Provider Demographics
NPI:1336132075
Name:LAZARO, ANDREA MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:MARIE
Last Name:LAZARO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ANDREA
Other - Middle Name:MARIE
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2712 MIDDLEBURG DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204
Mailing Address - Country:US
Mailing Address - Phone:803-254-4257
Mailing Address - Fax:803-252-7334
Practice Address - Street 1:2712 MIDDLEBURG DR
Practice Address - Street 2:SUITE 101 MIDLANDS PEDIATRICS
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204
Practice Address - Country:US
Practice Address - Phone:803-254-4257
Practice Address - Fax:803-252-7334
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16820208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC168204Medicaid
SC168204Medicaid