Provider Demographics
NPI:1912040197
Name:LAZARD, MARIELLE BAZILE (MD)
Entity Type:Individual
Prefix:
First Name:MARIELLE
Middle Name:BAZILE
Last Name:LAZARD
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 1:695 N CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2321
Mailing Address - Country:US
Mailing Address - Phone:386-258-8722
Mailing Address - Fax:386-258-8659
Practice Address - Street 1:938 SAXON BLVD
Practice Address - Street 2:SUITE 101-C
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8305
Practice Address - Country:US
Practice Address - Phone:386-774-5485
Practice Address - Fax:386-775-0761
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87805207UN0901X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL278018600Medicaid
FL88976OtherBC/BS
FL88976WMedicare PIN