Healthcare Provider Details

I. General information

NPI: 1285729152
Provider Name (Legal Business Name): LAZARO WISNIA, M.D., INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 S ATLANTIC BLVD SUITE 302
MONTEREY PARK CA
91754-4700
US

IV. Provider business mailing address

880 S ATLANTIC BLVD SUITE 302
MONTEREY PARK CA
91754-4700
US

V. Phone/Fax

Practice location:
  • Phone: 626-576-8040
  • Fax: 626-576-4186
Mailing address:
  • Phone: 626-576-8040
  • Fax: 626-576-4186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberA32074
License Number StateCA

VIII. Authorized Official

Name: LAZARO G. WISNIA
Title or Position: MEDICAL DOCTOR/DIRECTOR
Credential: M.D
Phone: 626-576-8040