Provider Demographics
NPI:1487618963
Name:LAZZARO, DOMENICO (MD)
Entity type:Individual
Prefix:
First Name:DOMENICO
Middle Name:
Last Name:LAZZARO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 957
Mailing Address - Street 2:
Mailing Address - City:SCHERERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46375-0957
Mailing Address - Country:US
Mailing Address - Phone:800-756-5986
Mailing Address - Fax:
Practice Address - Street 1:701 SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-4037
Practice Address - Country:US
Practice Address - Phone:219-934-2085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH01026137A207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00207505OtherRAILROAD MEDICARE
INE11178Medicare UPIN
IN223530AMedicare PIN