Healthcare Provider Details

I. General information

NPI: 1952644684
Provider Name (Legal Business Name): TOMAS ANTONIO LAZO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2013
Last Update Date: 09/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON PARK RD
PORTLAND OR
97239-3011
US

IV. Provider business mailing address

3181 SW SAM JACKSON PARK RD MAIL CODE SJH-2
PORTLAND OR
97239-3011
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-7641
  • Fax: 503-494-8368
Mailing address:
  • Phone: 503-494-4910
  • Fax: 503-494-8368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License NumberMD188191
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD188191
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: