Provider Demographics
NPI:1376505180
Name:LAZAR, MICHAEL J JR (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:LAZAR
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3536 MENDOCINO AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3634
Mailing Address - Country:US
Mailing Address - Phone:707-575-6049
Mailing Address - Fax:707-546-0725
Practice Address - Street 1:1140 SONOMA AVE
Practice Address - Street 2:STE 1A
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4817
Practice Address - Country:US
Practice Address - Phone:707-546-5553
Practice Address - Fax:707-546-0725
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC40958208800000X, 2088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00638732OtherRAILROAD MEDICARE
CA1376505180Medicaid
CA00C409580OtherBS OF CALIFORNIA
CA00C409580OtherBS OF CALIFORNIA
P00638732OtherRAILROAD MEDICARE