Provider Demographics
NPI:1144580085
Name:LAZZARA, JONATHAN I (DO)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:I
Last Name:LAZZARA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45005-5200
Mailing Address - Country:US
Mailing Address - Phone:513-974-5252
Mailing Address - Fax:
Practice Address - Street 1:4449 STATE ROUTE 159
Practice Address - Street 2:
Practice Address - City:CHILLICOTH
Practice Address - State:OH
Practice Address - Zip Code:45601-8620
Practice Address - Country:US
Practice Address - Phone:740-775-1260
Practice Address - Fax:740-773-1264
Is Sole Proprietor?:No
Enumeration Date:2012-05-25
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012788592084P0800X
OH34.011075208D00000X, 2084P0800X
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0116608Medicaid