Basic Information
| Provider Information | |||||||||
| NPI: | 1245413905 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAZARO FRAGA MD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4141 SW 6TH ST | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331342057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3053633675 | ||||||||
| FaxNumber: | 3054422207 | ||||||||
| Practice Location | |||||||||
| Address1: | 4131 SW 6TH ST | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331342057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054435031 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2007 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | CASANOVA | ||||||||
| AuthorizedOfficialFirstName: | RENE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3053633675 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 279233800 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | ACN961 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 273617000 | 05 | FL | MEDICAID | 279233800 | 05 | FL | MEDICAID |