MEDICARE: DR. THOMAS L LAZOFF 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	208VP0000X	Pain Medicine Physician	01040711A	IN
2	208100000X	Physical Medicine & Rehabilitation Physician	01040711A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00390615	OTHER	IN	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457354433
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS L LAZOFF M.D.

Provider Business Mailing Address
First Line	:	6920 POINTE INVERNESS WAY STE 200
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-7934
Country	:	US
Telephone Number	:	260-458-3640
Fax Number	:

Provider Business Practice Location Address
First Line	:	7956 W JEFFERSON BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-4140
Country	:	US
Telephone Number	:	260-458-3640
Fax Number	:	260-479-1819

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

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	02/07/2024

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