Healthcare Provider Details

I. General information

NPI: 1609835958
Provider Name (Legal Business Name): ALFREDO LAZO
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 W 13 MILE RD
ROYAL OAK MI
48073-6712
US

IV. Provider business mailing address

3601 W 13 MILE RD 400-FSC/PCS
ROYAL OAK MI
48073-6712
US

V. Phone/Fax

Practice location:
  • Phone: 248-898-6039
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301034863
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: