Healthcare Provider Details

I. General information

NPI: 1538554910
Provider Name (Legal Business Name): TIMOTHY LAZICKI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2015
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S PARK ST
MADISON WI
53715-1830
US

IV. Provider business mailing address

700 S PARK ST
MADISON WI
53715-1830
US

V. Phone/Fax

Practice location:
  • Phone: 608-251-6100
  • Fax: 608-258-5222
Mailing address:
  • Phone: 608-251-6100
  • Fax: 608-258-5222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number66782
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: