MEDICARE: JACK LAZERSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	5408	NV
2	2080P0207X	Pediatric Hematology & Oncology Physician	5408	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	CS04078	OTHER	NV	STATE PHARMACY

General Provider Information

NPI Number	:	1174501985
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK LAZERSON M.D.

Provider Business Mailing Address
First Line	:	2040 W CHARLESTON BLVD
Second Line	:	202-A
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-2227
Country	:	US
Telephone Number	:	702-671-2355
Fax Number	:	702-382-5388

Provider Business Practice Location Address
First Line	:	1524 PINTO LN
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-4195
Country	:	US
Telephone Number	:	702-671-2231
Fax Number	:	702-671-2233

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2006
Last Update Date	:	03/07/2023

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Directions to “ JACK LAZERSON M.D.” Practice Location

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