Healthcare Provider Details

I. General information

NPI: 1245286376
Provider Name (Legal Business Name): WILLIAM DOUGLAS LAZENBY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 06/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 W COLLEGE ST STE B
GRIFFIN GA
30224-4250
US

IV. Provider business mailing address

220 W COLLEGE ST STE B
GRIFFIN GA
30224-4250
US

V. Phone/Fax

Practice location:
  • Phone: 770-233-1080
  • Fax: 770-233-3680
Mailing address:
  • Phone: 770-233-1080
  • Fax: 770-233-3680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number051969
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: