Provider Demographics
NPI:1518050608
Name:LAZARUS, PETER S (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:S
Last Name:LAZARUS
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:PO BOX 99371
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0371
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-7347
Practice Address - Street 1:6421 MCCART AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-4702
Practice Address - Country:US
Practice Address - Phone:817-263-7500
Practice Address - Fax:817-423-4140
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE7157208000000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX134642104Medicaid
TX134642105Medicaid
TX138412505Medicaid
TX1392539OtherUHC PIN
TX10028668OtherAMERIGROUP PIN
TX138412507Medicaid
TX413475OtherPHCS PIN
TX00U87ZOtherBCBSTX GRP PIN
TX113052OtherSUPERIOR PIN
TX1640382OtherFIRSTHEALTH PIN
1750369203OtherGRP NPI NUMBER
TX82V082OtherBCBSTX IND PIN
TX9239598OtherCIGNA PIN
TX117492100OtherFIRSTCARE PIN
TX4391266OtherAETNA PIN
TX113052OtherSUPERIOR PIN
TX1392539OtherUHC PIN
TX00L96BMedicare PIN