Provider Demographics
NPI:1285733949
Name:MARC A. LAZZARA D.O., A MEDICAL CORPORATION
Entity type:Organization
Organization Name:MARC A. LAZZARA D.O., A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:LAZZARA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:714-544-8167
Mailing Address - Street 1:4521 CHARLEVILLE CIR
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-2329
Mailing Address - Country:US
Mailing Address - Phone:714-544-8167
Mailing Address - Fax:949-679-1909
Practice Address - Street 1:4521 CHARLEVILLE CIR
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-2329
Practice Address - Country:US
Practice Address - Phone:714-544-8167
Practice Address - Fax:949-679-1909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7964207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH10886Medicare UPIN
CAW17897Medicare ID - Type UnspecifiedGROUP ID
CAW20A7964AMedicare ID - Type UnspecifiedPPIN