Basic Information
| Provider Information | |||||||||
| NPI: | 1285610832 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAZZARO | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 E DUPONT RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603737875 | ||||||||
| FaxNumber: | 2603739705 | ||||||||
| Practice Location | |||||||||
| Address1: | 2708 GUILFORD ST | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467509701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603553900 | ||||||||
| FaxNumber: | 2603553079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 09/23/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01041253A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000368345 | 01 | IN | ANTHEM | OTHER | 5223 | 01 | IN | PHYSICIANS HEALTH PLAN | OTHER | 3937240023 | 01 | IN | MEDICARE DMEPOS | OTHER | 100095880 | 05 | IN | MEDICAID | P00315302 | 01 | IN | RAILROAD MEDICARE | OTHER |