Provider Demographics
NPI:1639264997
Name:LAZO, ELEONOR GUTIERREZ (MD)
Entity Type:Individual
Prefix:
First Name:ELEONOR
Middle Name:GUTIERREZ
Last Name:LAZO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELEONOR
Other - Middle Name:PIQUER
Other - Last Name:GUTIERREZ LAZO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:400 WEST MAIN STREET
Mailing Address - Street 2:SUITE 328
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702
Mailing Address - Country:US
Mailing Address - Phone:631-376-1002
Mailing Address - Fax:631-376-1004
Practice Address - Street 1:400 WEST MAIN STREET
Practice Address - Street 2:SUITE 328
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702
Practice Address - Country:US
Practice Address - Phone:631-376-1002
Practice Address - Fax:631-376-1004
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY197684208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01619781Medicaid
NY01619781Medicaid