Provider Demographics
NPI:1376552406
Name:LAZARE, JONATHAN NICHOLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:NICHOLAS
Last Name:LAZARE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1729 E 12TH ST FL 5
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-1088
Mailing Address - Country:US
Mailing Address - Phone:718-369-3300
Mailing Address - Fax:718-369-3301
Practice Address - Street 1:1729 E 12TH ST FL 5
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1088
Practice Address - Country:US
Practice Address - Phone:718-369-3300
Practice Address - Fax:718-369-3301
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY195845208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
340000207OtherMEDICARE CT
47H741Medicare ID - Type Unspecified