Healthcare Provider Details

I. General information

NPI: 1457354433
Provider Name (Legal Business Name): THOMAS L LAZOFF M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7956 W JEFFERSON BLVD
FORT WAYNE IN
46804-4140
US

IV. Provider business mailing address

6920 POINTE INVERNESS WAY STE 200
FORT WAYNE IN
46804-7934
US

V. Phone/Fax

Practice location:
  • Phone: 260-458-3640
  • Fax: 260-479-1819
Mailing address:
  • Phone: 260-458-3640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number01040711A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number01040711A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: