Healthcare Provider Details

I. General information

NPI: 1508088618
Provider Name (Legal Business Name): BARRY MARSHALL LAZENBY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 03/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E WOOD ST
SPARTANBURG SC
29303-3040
US

IV. Provider business mailing address

PO BOX 678207
DALLAS TX
75267-8207
US

V. Phone/Fax

Practice location:
  • Phone: 864-560-6522
  • Fax: 888-972-8644
Mailing address:
  • Phone: 800-841-4236
  • Fax: 706-653-1162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number31652
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA104418
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: