Healthcare Provider Details

I. General information

NPI: 1245413905
Provider Name (Legal Business Name): LAZARO FRAGA MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4131 SW 6TH ST
CORAL GABLES FL
33134-2057
US

IV. Provider business mailing address

4141 SW 6TH ST
CORAL GABLES FL
33134-2057
US

V. Phone/Fax

Practice location:
  • Phone: 305-443-5031
  • Fax:
Mailing address:
  • Phone: 305-363-3675
  • Fax: 305-442-2207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number279233800
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberACN961
License Number StateFL

VIII. Authorized Official

Name: RENE CASANOVA
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 305-363-3675