Provider Demographics
NPI:1619726890
Name:LAZZARA DERMATOLOGY & MOHS SURGERY OF MILTON, LLC
Entity type:Organization
Organization Name:LAZZARA DERMATOLOGY & MOHS SURGERY OF MILTON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:RAFFAELLA
Authorized Official - Last Name:LAZZARA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:732-977-8371
Mailing Address - Street 1:12455 BROADWELL RD STE 102-103
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:GA
Mailing Address - Zip Code:30004-6315
Mailing Address - Country:US
Mailing Address - Phone:770-375-6197
Mailing Address - Fax:770-215-7577
Practice Address - Street 1:12455 BROADWELL RD STE 102-103
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:GA
Practice Address - Zip Code:30004-6315
Practice Address - Country:US
Practice Address - Phone:770-375-6197
Practice Address - Fax:770-215-7577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-18
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty