Healthcare Provider Details

I. General information

NPI: 1043265556
Provider Name (Legal Business Name): ANDREW LAZERE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 11/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31872 SOUTH COAST HIGHWAY RADIOLOGY DEPARTMENT
LAGUNA BEACH CA
92651
US

IV. Provider business mailing address

DEPT LA 21650
PASADENA CA
91185-1650
US

V. Phone/Fax

Practice location:
  • Phone: 949-499-7195
  • Fax:
Mailing address:
  • Phone: 949-263-8620
  • Fax: 949-263-1639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG20742
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: