Basic Information
| Provider Information | |||||||||
| NPI: | 1891830345 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAZOFF | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16229 CANYON RUN | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468459082 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1100 MERCER AVE | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467332303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2607242145 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 06/18/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 01048939A | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 01048939A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.