Provider Demographics
NPI:1699858936
Name:LAZO FAMILY MEDICINE INC
Entity Type:Organization
Organization Name:LAZO FAMILY MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FAUSTO
Authorized Official - Middle Name:J
Authorized Official - Last Name:LAZO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-635-4572
Mailing Address - Street 1:55741 NATIONAL RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43912-1528
Mailing Address - Country:US
Mailing Address - Phone:740-635-4572
Mailing Address - Fax:740-635-4575
Practice Address - Street 1:55741 NATIONAL RD
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:OH
Practice Address - Zip Code:43912
Practice Address - Country:US
Practice Address - Phone:740-635-4572
Practice Address - Fax:740-635-4575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0458339Medicaid
WV3810016451Medicaid
WV3810016451Medicaid