Provider Demographics
NPI:1528041001
Name:WISNIA, LAZARO GUROVICH (MD)
Entity Type:Individual
Prefix:DR
First Name:LAZARO
Middle Name:GUROVICH
Last Name:WISNIA
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 1:880 S ATLANTIC BLVD
Mailing Address - Street 2:#302
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-4700
Mailing Address - Country:US
Mailing Address - Phone:626-576-8040
Mailing Address - Fax:626-576-8079
Practice Address - Street 1:880 S ATLANTIC BLVD
Practice Address - Street 2:#302
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-4700
Practice Address - Country:US
Practice Address - Phone:626-576-8040
Practice Address - Fax:626-576-8079
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32074174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A320741Medicaid
CAA32074Medicare ID - Type UnspecifiedMEDICARE
CA00A320741Medicaid