Provider Demographics
NPI:1710907381
Name:LAZAR, MARK A (DPM)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:LAZAR
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6415 GREYRIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-3145
Mailing Address - Country:US
Mailing Address - Phone:317-788-7841
Mailing Address - Fax:
Practice Address - Street 1:720 FRY RD
Practice Address - Street 2:STE. A
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-2410
Practice Address - Country:US
Practice Address - Phone:317-881-0788
Practice Address - Fax:317-889-0775
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0700059-1213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100137150AMedicaid
IN591000AMedicare ID - Type Unspecified
IN100137150AMedicaid