Provider Demographics
NPI:1619958170
Name:LEZAMA, NICHOLAS G (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:G
Last Name:LEZAMA
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 1:901 THORNBURY PL
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-6811
Mailing Address - Country:US
Mailing Address - Phone:618-229-5220
Mailing Address - Fax:
Practice Address - Street 1:901 THORNBURY PL
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-6811
Practice Address - Country:US
Practice Address - Phone:618-229-5220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2009-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA770822083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine