Healthcare Provider Details

I. General information

NPI: 1962436279
Provider Name (Legal Business Name): JACKSON LAZARD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 DEKALB AVE
BROOKLYN NY
11201-5425
US

IV. Provider business mailing address

121 DEKALB AVE
BROOKLYN NY
11201-5425
US

V. Phone/Fax

Practice location:
  • Phone: 718-250-8848
  • Fax: 718-250-8850
Mailing address:
  • Phone: 718-250-8848
  • Fax: 718-250-8850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberP47529
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: