Provider Demographics
NPI:1568449007
Name:LAZARO, LARRY RIVERA (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:RIVERA
Last Name:LAZARO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1721 S STEPHENSON AVE
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-3637
Mailing Address - Country:US
Mailing Address - Phone:810-692-4030
Mailing Address - Fax:616-222-0284
Practice Address - Street 1:1721 S STEPHENSON AVE
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-3637
Practice Address - Country:US
Practice Address - Phone:810-692-4030
Practice Address - Fax:616-222-0284
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301069069207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4786502Medicaid
MILL069069OtherBLUE CROSS PIN
MIG83223Medicare UPIN
MAM59260015Medicare UPIN