Provider Demographics
NPI:1649237157
Name:LAZO, IVAN E (MD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:E
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 1:441 PINEY FOREST RD STE A
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-4154
Mailing Address - Country:US
Mailing Address - Phone:434-799-5700
Mailing Address - Fax:434-799-4693
Practice Address - Street 1:441 PINEY FOREST RD STE A
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-4154
Practice Address - Country:US
Practice Address - Phone:434-799-5700
Practice Address - Fax:434-799-4693
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101051102207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA285572OtherBCBS
VA080007539Medicare ID - Type Unspecified
VA285572OtherBCBS