Healthcare Provider Details

I. General information

NPI: 1396729547
Provider Name (Legal Business Name): EDWARD JOSEPH LAZAGA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 05/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222 MCCULLOUGH AVE SUITE 101
SAN ANTONIO TX
78212-4812
US

IV. Provider business mailing address

1222 MCCULLOUGH AVE SUITE 101
SAN ANTONIO TX
78212-4812
US

V. Phone/Fax

Practice location:
  • Phone: 210-223-4140
  • Fax: 210-359-6640
Mailing address:
  • Phone: 210-223-4140
  • Fax: 210-359-6640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberL7950
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: