Healthcare Provider Details

I. General information

NPI: 1003883349
Provider Name (Legal Business Name): GERALD MARTIN LAZAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 07/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 E 2700 S SUITE 180
SALT LAKE CITY UT
84109-1700
US

IV. Provider business mailing address

4187 NEPTUNE DR
SALT LAKE CITY UT
84124-3343
US

V. Phone/Fax

Practice location:
  • Phone: 801-746-2297
  • Fax: 801-322-3890
Mailing address:
  • Phone: 801-272-1777
  • Fax: 801-322-3890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number174906-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: