Provider Demographics
NPI:1396818027
Name:LAZARO, VIRGINIA M
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:M
Last Name:LAZARO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 DELAWARE AVENUE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12209
Mailing Address - Country:US
Mailing Address - Phone:518-689-2354
Mailing Address - Fax:518-462-0715
Practice Address - Street 1:834 KENWOOD AVENUE
Practice Address - Street 2:
Practice Address - City:SLINGERLANDS
Practice Address - State:NY
Practice Address - Zip Code:12159
Practice Address - Country:US
Practice Address - Phone:518-439-2596
Practice Address - Fax:518-439-0428
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111379207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00523542Medicaid
B79381Medicare UPIN
NY00523542Medicaid