Healthcare Provider Details

I. General information

NPI: 1104094739
Provider Name (Legal Business Name): MARK GREGORY LAZAREV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2008
Last Update Date: 02/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N WOLFE ST 1830 BLDG, RM 420
BALTIMORE MD
21287-0006
US

IV. Provider business mailing address

PO BOX 64264
BALTIMORE MD
21264-4264
US

V. Phone/Fax

Practice location:
  • Phone: 410-614-6708
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMT185907
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberD69337
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: