Healthcare Provider Details

I. General information

NPI: 1790756856
Provider Name (Legal Business Name): MARIO A LANZA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 11/12/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 MEDICAL CENTER DR
NEWTON KS
67114-8778
US

IV. Provider business mailing address

720 MEDICAL CENTER DR
NEWTON KS
67114-8778
US

V. Phone/Fax

Practice location:
  • Phone: 316-283-6103
  • Fax: 907-258-1257
Mailing address:
  • Phone: 316-283-6103
  • Fax: 316-283-1333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3753
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number04-43901
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: