Provider Demographics
NPI:1093806382
Name:LAZAR, SHELLEE RAE (MD)
Entity type:Individual
Prefix:DR
First Name:SHELLEE
Middle Name:RAE
Last Name:LAZAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHELLEE
Other - Middle Name:RAE
Other - Last Name:MIYASATO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 9595
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92375-2795
Mailing Address - Country:US
Mailing Address - Phone:909-335-5616
Mailing Address - Fax:909-307-7518
Practice Address - Street 1:350 TERRACINA BLVD
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4850
Practice Address - Country:US
Practice Address - Phone:909-335-5616
Practice Address - Fax:909-307-7518
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA669212083P0011X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A669210Medicaid
CA1467402149Medicaid
CA1467402149Medicaid