Healthcare Provider Details

I. General information

NPI: 1699277889
Provider Name (Legal Business Name): KAMAL LAZAR DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2018
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4112 OUTLOOK BLVD STE 303
PUEBLO CO
81008-1667
US

IV. Provider business mailing address

902 LAKEVIEW AVE
PUEBLO CO
81004-3597
US

V. Phone/Fax

Practice location:
  • Phone: 719-557-8600
  • Fax: 719-557-8615
Mailing address:
  • Phone: 719-557-5855
  • Fax: 719-557-5097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0073760
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: