Healthcare Provider Details

I. General information

NPI: 1407854821
Provider Name (Legal Business Name): HARRISON M LAZARUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2005
Last Update Date: 08/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3584 W 9000 S STE 400
WEST JORDAN UT
84088-5710
US

IV. Provider business mailing address

PO BOX 27688
SALT LAKE CITY UT
84127-0688
US

V. Phone/Fax

Practice location:
  • Phone: 801-263-0788
  • Fax: 801-569-2080
Mailing address:
  • Phone: 801-534-1360
  • Fax: 801-366-9883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number1529831205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: