Provider Demographics
NPI:1962507186
Name:LAZARUS, GARY M (OD)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:M
Last Name:LAZARUS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5253 BUFFALO AVE
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-5930
Mailing Address - Country:US
Mailing Address - Phone:818-789-4697
Mailing Address - Fax:818-789-3618
Practice Address - Street 1:5253 BUFFALO AVE
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91401-5930
Practice Address - Country:US
Practice Address - Phone:818-789-4697
Practice Address - Fax:818-789-3618
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5171152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT09892Medicare UPIN
CAWOP5171Medicare ID - Type Unspecified