Healthcare Provider Details

I. General information

NPI: 1083619431
Provider Name (Legal Business Name): MARK LAZAROVICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 TIMBER LN
SOUTH BURLINGTON VT
05403-5201
US

IV. Provider business mailing address

53 TIMBER LN
SOUTH BURLINGTON VT
05403-5201
US

V. Phone/Fax

Practice location:
  • Phone: 802-864-0294
  • Fax: 802-864-3779
Mailing address:
  • Phone: 802-864-0294
  • Fax: 802-864-3779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: