Healthcare Provider Details

I. General information

NPI: 1851038715
Provider Name (Legal Business Name): VLADISLAV LAZAREV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2022
Last Update Date: 05/12/2022
Certification Date: 05/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 LIBERTY ST
SPRINGFIELD MA
01104-3736
US

IV. Provider business mailing address

417 LIBERTY ST
SPRINGFIELD MA
01104-3736
US

V. Phone/Fax

Practice location:
  • Phone: 413-733-6661
  • Fax: 413-733-7841
Mailing address:
  • Phone: 413-733-6661
  • Fax: 413-733-7841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: