Provider Demographics
NPI:1912910811
Name:MICHAEL J. LAZAR, JR., M.D., PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:MICHAEL J. LAZAR, JR., M.D., PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:LAZAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-546-5553
Mailing Address - Street 1:1140 SONOMA AVE
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4817
Mailing Address - Country:US
Mailing Address - Phone:707-546-5553
Mailing Address - Fax:707-546-0725
Practice Address - Street 1:1140 SONOMA AVE
Practice Address - Street 2:SUITE 1A
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4817
Practice Address - Country:US
Practice Address - Phone:707-546-5553
Practice Address - Fax:707-546-0725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C409580Medicaid
CAA37485Medicare UPIN
CA00C409580Medicare ID - Type Unspecified