Healthcare Provider Details

I. General information

NPI: 1629566070
Provider Name (Legal Business Name): MATTHEW R LAZARUS OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2018
Last Update Date: 02/23/2024
Certification Date: 02/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5311 CAROLINE DR
HIGH RIDGE MO
63049-2481
US

IV. Provider business mailing address

5311 CAROLINE DR
HIGH RIDGE MO
63049-2481
US

V. Phone/Fax

Practice location:
  • Phone: 636-489-0133
  • Fax: 636-489-1403
Mailing address:
  • Phone: 636-489-0133
  • Fax: 636-489-1403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2018021523
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: