Provider Demographics
NPI:1760452544
Name:LAZZARINI, AMY L (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:LAZZARINI
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 1:4926 TANGLEWOOD LANE
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104
Mailing Address - Country:US
Mailing Address - Phone:153-727-1846
Mailing Address - Fax:
Practice Address - Street 1:1386 STATE ROUTE 5 WEST SUITE 203
Practice Address - Street 2:
Practice Address - City:CHITTENANGO
Practice Address - State:NY
Practice Address - Zip Code:13037
Practice Address - Country:US
Practice Address - Phone:315-741-5774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101261421207RG0100X
NY2075561207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02527195Medicaid
NYI07272Medicare UPIN
NYAA0363Medicare ID - Type UnspecifiedMEDICARE
NY34594AMedicare ID - Type UnspecifiedMEDICARE
NY02527195Medicaid