Provider Demographics
NPI:1245286376
Name:LAZENBY, WILLIAM DOUGLAS (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:DOUGLAS
Last Name:LAZENBY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:220 W COLLEGE ST STE B
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4250
Mailing Address - Country:US
Mailing Address - Phone:770-233-1080
Mailing Address - Fax:770-233-3680
Practice Address - Street 1:220 W COLLEGE ST STE B
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4250
Practice Address - Country:US
Practice Address - Phone:770-233-1080
Practice Address - Fax:770-233-3680
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051969208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I025868OtherMEDICARE PTAN
GA02BBGHFMedicare ID - Type Unspecified
F76926Medicare UPIN