Healthcare Provider Details

I. General information

NPI: 1124123708
Provider Name (Legal Business Name): JOEL DEAN LAZAR PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1267 ROSECRANS ST SUITE E
SAN DIEGO CA
92106
US

IV. Provider business mailing address

1267 ROSECRANS ST SUITE E
SAN DIEGO CA
92106
US

V. Phone/Fax

Practice location:
  • Phone: 619-540-6038
  • Fax: 619-426-1906
Mailing address:
  • Phone: 619-540-6038
  • Fax: 619-426-1906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY12520
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: