Healthcare Provider Details

I. General information

NPI: 1285733949
Provider Name (Legal Business Name): MARC A. LAZZARA D.O., A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 12/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4521 CHARLEVILLE CIR
IRVINE CA
92604-2329
US

IV. Provider business mailing address

4521 CHARLEVILLE CIR
IRVINE CA
92604-2329
US

V. Phone/Fax

Practice location:
  • Phone: 714-544-8167
  • Fax: 949-679-1909
Mailing address:
  • Phone: 714-544-8167
  • Fax: 949-679-1909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number20A7964
License Number StateCA

VIII. Authorized Official

Name: DR. MARC ADAM LAZZARA
Title or Position: CEO
Credential: D.O.
Phone: 714-544-8167