Provider Demographics
NPI:1285794057
Name:LAZARNICK, PETER GARY (DC)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:GARY
Last Name:LAZARNICK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 FOGGY BOTTOM DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30116-8047
Mailing Address - Country:US
Mailing Address - Phone:770-834-7377
Mailing Address - Fax:770-834-0251
Practice Address - Street 1:486 BANKHEAD HWY
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-2445
Practice Address - Country:US
Practice Address - Phone:770-834-7477
Practice Address - Fax:770-834-0251
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR001151111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1C GRP7356OtherMEDICARE GROUP
GA1C GRP7356OtherMEDICARE GROUP