Basic Information
| Provider Information | |||||||||
| NPI: | 1780623793 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAZZARO | ||||||||
| FirstName: | CARLO | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5901 TECHNOLOGY CENTER DR | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462786013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173283746 | ||||||||
| FaxNumber: | 3175706432 | ||||||||
| Practice Location | |||||||||
| Address1: | 5901 TECHNOLOGY CENTER DRIVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173284777 | ||||||||
| FaxNumber: | 3177159965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 10/03/2016 | ||||||||
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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 | 2085R0202X | 01062010 | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 200822810 | 05 | IN | MEDICAID |