Provider Demographics
NPI:1619991981
Name:LAZARUS, SEAN WAYNE (DPM)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:WAYNE
Last Name:LAZARUS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:764 CAMPBELL AVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-3786
Mailing Address - Country:US
Mailing Address - Phone:475-238-7400
Mailing Address - Fax:475-238-7982
Practice Address - Street 1:764 CAMPBELL AVE
Practice Address - Street 2:SUITE G
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-3786
Practice Address - Country:US
Practice Address - Phone:475-238-7400
Practice Address - Fax:475-238-7982
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000642213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1619991981OtherNPI
CT480023259Medicare PIN
CTU55872Medicare UPIN
CT1155230003Medicare NSC
CT004213279Medicaid