Basic Information
| Provider Information | |||||||||
| NPI: | 1619469905 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAZZARIN | ||||||||
| FirstName: | BRYAN | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118 CASS AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT CLEMENS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480432204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864641479 | ||||||||
| FaxNumber: | 5864641480 | ||||||||
| Practice Location | |||||||||
| Address1: | 30120 HARPER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867787542 | ||||||||
| FaxNumber: | 5867781848 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2018 | ||||||||
| LastUpdateDate: | 07/20/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4901005152 | MI | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.