Basic Information
| Provider Information | |||||||||
| NPI: | 1548214059 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAZOR | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LAZOR-MCDANIEL | ||||||||
| OtherFirstName: | BONNIE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1110 OAKWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | OAKWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454192911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192061249 | ||||||||
| FaxNumber: | 9375670670 | ||||||||
| Practice Location | |||||||||
| Address1: | 1110 OAKWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | OAKWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192061249 | ||||||||
| FaxNumber: | 9375670670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 03/13/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 38890 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000479105 | 01 | ANTHEM BCBS | OTHER | P00343016 | 01 | RAILROAD MEDICARE | OTHER | 50011328 | 01 | PASSPORT | OTHER | 743176351A | 01 | HUMANA | OTHER | 2746336000 | 01 | PASSPORT ADVANTAGE | OTHER | 64089535 | 05 | KY | MEDICAID |