Provider Demographics
NPI:1982993309
Name:LAZOFF, SHAWN P (DO)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:P
Last Name:LAZOFF
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-716-1331
Mailing Address - Fax:336-716-3202
Practice Address - Street 1:4431 US HIGHWAY 220 N
Practice Address - Street 2:
Practice Address - City:SUMMERFIELD
Practice Address - State:NC
Practice Address - Zip Code:27358-9411
Practice Address - Country:US
Practice Address - Phone:336-643-7711
Practice Address - Fax:336-643-3047
Is Sole Proprietor?:No
Enumeration Date:2011-04-06
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02004719A207Q00000X
NC2020-04121207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201337850Medicaid
IN201337850Medicaid