Provider Demographics
NPI:1205915527
Name:RICHARD W LAZARO MD PC
Entity type:Organization
Organization Name:RICHARD W LAZARO MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CORINE
Authorized Official - Middle Name:B
Authorized Official - Last Name:LAZARO
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:505-522-7676
Mailing Address - Street 1:1131 MALL DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011
Mailing Address - Country:US
Mailing Address - Phone:505-522-7676
Mailing Address - Fax:505-522-8121
Practice Address - Street 1:1131 MALL DRIVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011
Practice Address - Country:US
Practice Address - Phone:505-522-7676
Practice Address - Fax:505-522-8121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6127261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM40006Medicaid