Healthcare Provider Details

I. General information

NPI: 1619664588
Provider Name (Legal Business Name): BRANDON LEO LAZAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2023
Last Update Date: 04/20/2023
Certification Date: 04/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 MULLICA HILL RD
MULLICA HILL NJ
08062-4413
US

IV. Provider business mailing address

700 MULLICA HILL RD
MULLICA HILL NJ
08062-4413
US

V. Phone/Fax

Practice location:
  • Phone: 856-508-8000
  • Fax:
Mailing address:
  • Phone: 856-508-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number208100000X
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: