Healthcare Provider Details

I. General information

NPI: 1215184569
Provider Name (Legal Business Name): IVANA LAZICH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2008
Last Update Date: 12/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 ESSEX CENTER DR SUITE 306
PEABODY MA
01960-2904
US

IV. Provider business mailing address

6 ESSEX CENTER DR SUITE 306
PEABODY MA
01960-2904
US

V. Phone/Fax

Practice location:
  • Phone: 978-531-0677
  • Fax: 978-531-5676
Mailing address:
  • Phone: 978-531-0677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number261159
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: