Provider Demographics
NPI:1659532307
Name:LAZERNICK, SAMARA D (MD)
Entity Type:Individual
Prefix:
First Name:SAMARA
Middle Name:D
Last Name:LAZERNICK
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 1:196 E. 2000 N.
Mailing Address - Street 2:SUITE 104
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074
Mailing Address - Country:US
Mailing Address - Phone:435-843-2576
Mailing Address - Fax:
Practice Address - Street 1:196 E. 2000 N.
Practice Address - Street 2:SUITE 104
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074
Practice Address - Country:US
Practice Address - Phone:435-843-2576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8229754-1205207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology