Healthcare Provider Details

I. General information

NPI: 1023898566
Provider Name (Legal Business Name): MAYRA CAROLINA LAZO OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2023
Last Update Date: 10/03/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6765 LANKERSHIM BLVD
NORTH HOLLYWOOD CA
91606-1614
US

IV. Provider business mailing address

15243 CANTLAY ST
VAN NUYS CA
91405-2002
US

V. Phone/Fax

Practice location:
  • Phone: 818-982-0076
  • Fax:
Mailing address:
  • Phone: 818-445-6816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number35599
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: