Healthcare Provider Details

I. General information

NPI: 1619464260
Provider Name (Legal Business Name): CHASE WESLEY LAZENBY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2018
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W GRAND AVE
DAYTON OH
45405-7538
US

IV. Provider business mailing address

405 W GRAND AVE
DAYTON OH
45405-7538
US

V. Phone/Fax

Practice location:
  • Phone: 937-723-3245
  • Fax:
Mailing address:
  • Phone: 937-723-3245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number9445
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number34.014118
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: