Healthcare Provider Details

I. General information

NPI: 1679682256
Provider Name (Legal Business Name): REYNALDO P LAZARO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 08/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41-45 DIETZ ST
ONEONTA NY
13820-1855
US

IV. Provider business mailing address

41-45 DIETZ ST
ONEONTA NY
13820-1855
US

V. Phone/Fax

Practice location:
  • Phone: 607-432-8272
  • Fax: 607-441-5051
Mailing address:
  • Phone: 607-432-8272
  • Fax: 607-441-5051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number124398-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: