=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184649717
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SVETISLAV LAZICH MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2006
-----------------------------------------------------
Last Update Date | 06/01/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 532 LEBANON ST
-----------------------------------------------------
City | MELROSE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-665-3237
-----------------------------------------------------
Fax | 781-662-6452
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 532 LEBANON ST
-----------------------------------------------------
City | MELROSE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-665-3237
-----------------------------------------------------
Fax | 781-662-6452
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number | 35303
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------