Provider Demographics
NPI:1083789366
Name:GARY M LAZARUS OD PHD APC
Entity type:Organization
Organization Name:GARY M LAZARUS OD PHD APC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:MARC
Authorized Official - Last Name:LAZARUS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:310-372-2197
Mailing Address - Street 1:806 MANHATTAN BEACH BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-4960
Mailing Address - Country:US
Mailing Address - Phone:310-372-2197
Mailing Address - Fax:310-372-6581
Practice Address - Street 1:806 MANHATTAN BEACH BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-4960
Practice Address - Country:US
Practice Address - Phone:310-372-2197
Practice Address - Fax:310-372-6581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5171T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0051710OtherBLUE SHILE OF CA
CA32660VEMedicaid
CASD0051710Medicaid
CA32660VEMedicaid
CASD0051710OtherBLUE SHILE OF CA