Provider Demographics
NPI:1508850702
Name:LAZER, BOB L (OD)
Entity Type:Individual
Prefix:
First Name:BOB
Middle Name:L
Last Name:LAZER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W PENN ST
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15522-1223
Mailing Address - Country:US
Mailing Address - Phone:814-623-5018
Mailing Address - Fax:814-623-7718
Practice Address - Street 1:120 W PENN ST
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:PA
Practice Address - Zip Code:15522-1223
Practice Address - Country:US
Practice Address - Phone:814-623-5018
Practice Address - Fax:814-623-7718
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001149152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PALA435357OtherBLUE SHIELD
PAT30418Medicare UPIN
PA0511690001Medicare NSC
PA435357Medicare PIN