Provider Demographics
NPI:1548214059
Name:LAZOR, BONNIE A (MD)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:A
Last Name:LAZOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:
Other - Last Name:LAZOR-MCDANIEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1110 OAKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:OAKWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45419-2911
Mailing Address - Country:US
Mailing Address - Phone:419-206-1249
Mailing Address - Fax:937-567-0670
Practice Address - Street 1:1110 OAKWOOD AVE
Practice Address - Street 2:
Practice Address - City:OAKWOOD
Practice Address - State:OH
Practice Address - Zip Code:45419
Practice Address - Country:US
Practice Address - Phone:419-206-1249
Practice Address - Fax:937-567-0670
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38890207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000479105OtherANTHEM BCBS
P00343016OtherRAILROAD MEDICARE
50011328OtherPASSPORT
743176351AOtherHUMANA
2746336000OtherPASSPORT ADVANTAGE
KY64089535Medicaid
KYI19393Medicare UPIN
KY64089535Medicaid
KY00018001Medicare PIN