Healthcare Provider Details

I. General information

NPI: 1306996269
Provider Name (Legal Business Name): BRUCE LEE LAZEROW B.A., B.S., O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2612 OAKENSHIELD DR
POTOMAC MD
20854-2928
US

IV. Provider business mailing address

2612 OAKENSHIELD DR
POTOMAC MD
20854-2928
US

V. Phone/Fax

Practice location:
  • Phone: 301-340-7674
  • Fax: 301-593-7006
Mailing address:
  • Phone: 301-340-7674
  • Fax: 301-593-7006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberDA-0688
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: