MEDICARE: BOB L LAZER OD

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	152W00000X	Optometrist	OEG001149	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LA435357	OTHER	PA	BLUE SHIELD

General Provider Information

NPI Number	:	1508850702
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BOB L LAZER OD

Provider Business Mailing Address
First Line	:	120 W PENN ST
Second Line	:
City	:	BEDFORD
State	:	PA
Zip	:	15522-1223
Country	:	US
Telephone Number	:	814-623-5018
Fax Number	:	814-623-7718

Provider Business Practice Location Address
First Line	:	120 W PENN ST
Second Line	:
City	:	BEDFORD
State	:	PA
Zip	:	15522-1223
Country	:	US
Telephone Number	:	814-623-5018
Fax Number	:	814-623-7718

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

Provider Enumeration Date	:	09/02/2005
Last Update Date	:	05/22/2008

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Directions to “ BOB L LAZER OD” Practice Location

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