Provider Demographics
NPI:1578646808
Name:LAZO, FAUSTO J (MD)
Entity Type:Individual
Prefix:
First Name:FAUSTO
Middle Name:J
Last Name:LAZO
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 1:55741 NATIONAL RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43912
Mailing Address - Country:US
Mailing Address - Phone:740-635-4572
Mailing Address - Fax:740-635-4575
Practice Address - Street 1:55741 NATIONAL RD
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:OH
Practice Address - Zip Code:43912
Practice Address - Country:US
Practice Address - Phone:740-635-4572
Practice Address - Fax:740-635-4575
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH44336207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0456886Medicaid
OH0456886Medicaid
E29704Medicare UPIN