Provider Demographics
NPI:1790834067
Name:MIRKIN, LAZARO DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:LAZARO
Middle Name:DAVID
Last Name:MIRKIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8890 WINTON HILLS CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-9620
Mailing Address - Country:US
Mailing Address - Phone:937-748-0809
Mailing Address - Fax:
Practice Address - Street 1:ONE CHILDREN'S PLAZA
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45404-1815
Practice Address - Country:US
Practice Address - Phone:937-641-3358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35055097174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist