Provider Demographics
NPI:1285729152
Name:LAZARO WISNIA, M.D., INC
Entity type:Organization
Organization Name:LAZARO WISNIA, M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAZARO
Authorized Official - Middle Name:G
Authorized Official - Last Name:WISNIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-576-8040
Mailing Address - Street 1:880 S ATLANTIC BLVD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-4700
Mailing Address - Country:US
Mailing Address - Phone:626-576-8040
Mailing Address - Fax:626-576-4186
Practice Address - Street 1:880 S ATLANTIC BLVD
Practice Address - Street 2:SUITE 302
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-4700
Practice Address - Country:US
Practice Address - Phone:626-576-8040
Practice Address - Fax:626-576-4186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32074208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A320741Medicaid
CA00A320741Medicaid
CAA32074Medicare PIN