Healthcare Provider Details

I. General information

NPI: 1083709299
Provider Name (Legal Business Name): LESLIE MARIE LAZORE-MACK DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 12/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1903 MORGANTOWN RD
READING PA
19607
US

IV. Provider business mailing address

1903 MORGANTOWN RD
READING PA
19607
US

V. Phone/Fax

Practice location:
  • Phone: 610-777-4040
  • Fax: 610-777-5575
Mailing address:
  • Phone: 610-777-4040
  • Fax: 610-777-5575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS012389
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: