Provider Demographics
NPI:1629262126
Name:LAZO, MARCELA A (MD)
Entity Type:Individual
Prefix:
First Name:MARCELA
Middle Name:A
Last Name:LAZO
Suffix:
Gender:F
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:PO BOX 25317
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33622-5317
Mailing Address - Country:US
Mailing Address - Phone:813-286-0033
Mailing Address - Fax:813-282-1806
Practice Address - Street 1:4671 S CONGRESS AVE
Practice Address - Street 2:SUITE 100B
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-4783
Practice Address - Country:US
Practice Address - Phone:561-434-0111
Practice Address - Fax:561-296-3533
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
FLME110131207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLLN461OtherMEDICARE
14FW0OtherBCBS
FL004197300Medicaid