Healthcare Provider Details

I. General information

NPI: 1205036829
Provider Name (Legal Business Name): ALLEN LAZERSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2007
Last Update Date: 08/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 POWERS FERRY RD SUITE 103
MARIETTA GA
30067-9414
US

IV. Provider business mailing address

1234 POWERS FERRY RD SUITE 103
MARIETTA GA
30067-9414
US

V. Phone/Fax

Practice location:
  • Phone: 770-951-8976
  • Fax: 770-951-8988
Mailing address:
  • Phone: 770-951-8976
  • Fax: 770-951-8988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number000496
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberPOD000496
License Number StateGA

VIII. Authorized Official

Name: DR. ALLEN LAZERSON
Title or Position: OWNER
Credential: DPM
Phone: 770-951-8976