Healthcare Provider Details

I. General information

NPI: 1023323086
Provider Name (Legal Business Name): LAZARO BOUZA MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2010
Last Update Date: 08/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3611 SW 107TH AVE
MIAMI FL
33165-3636
US

IV. Provider business mailing address

3611 SW 107TH AVE
MIAMI FL
33165-3636
US

V. Phone/Fax

Practice location:
  • Phone: 305-226-4634
  • Fax: 305-226-5154
Mailing address:
  • Phone: 305-226-4634
  • Fax: 305-226-5154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME0042893
License Number StateFL

VIII. Authorized Official

Name: LAZARO BOUZA
Title or Position: MEDICAL DOCTOR/PRESIDENT
Credential: M.D.
Phone: 305-226-4634