Healthcare Provider Details

I. General information

NPI: 1518329754
Provider Name (Legal Business Name): ANGEL LAZO III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2016
Last Update Date: 04/28/2020
Certification Date: 04/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 KINGSLEY AVE
ORANGE PARK FL
32073-5148
US

IV. Provider business mailing address

5700 DARROW RD STE 106
HUDSON OH
44236-5026
US

V. Phone/Fax

Practice location:
  • Phone: 904-639-2018
  • Fax:
Mailing address:
  • Phone: 732-309-4844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35.136127
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: