Healthcare Provider Details

I. General information

NPI: 1104266956
Provider Name (Legal Business Name): JONATHAN RAFAEL JAVIER LAZARO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2013
Last Update Date: 11/16/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 S STAPLEY DR STE 101
MESA AZ
85204-6682
US

IV. Provider business mailing address

2750 SHADOW VIEW DR APT 224
EUGENE OR
97408-4642
US

V. Phone/Fax

Practice location:
  • Phone: 480-464-8500
  • Fax: 480-464-6910
Mailing address:
  • Phone: 412-330-0034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD177853
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number61339
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: