Healthcare Provider Details

I. General information

NPI: 1982742292
Provider Name (Legal Business Name): ILUMINADA ILAW LAZARO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ILUMINADA ILAW HERNANDEZ MD

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 CHERRY HILL ROAD
BALTIMORE MD
21225
US

IV. Provider business mailing address

6917 PINECREST ROAD
CATONSVILLE MD
21228
US

V. Phone/Fax

Practice location:
  • Phone: 443-872-7800
  • Fax: 443-872-7803
Mailing address:
  • Phone: 410-455-0192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD18885
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: