Provider Demographics
NPI:1689602385
Name:LAZARUS, KENNETH J (MD,PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:J
Last Name:LAZARUS
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Gender:M
Credentials:MD,PHD
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Mailing Address - Street 1:1250 HIGHWAY 54 W
Mailing Address - Street 2:STE. 102
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4545
Mailing Address - Country:US
Mailing Address - Phone:770-719-2965
Mailing Address - Fax:770-719-2963
Practice Address - Street 1:1250 HIGHWAY 54 W
Practice Address - Street 2:STE. 102
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4545
Practice Address - Country:US
Practice Address - Phone:770-719-2965
Practice Address - Fax:770-719-2963
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2012-02-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA0310582084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000406975DMedicaid
GA000406975DMedicaid
GAE19956Medicare UPIN