Provider Demographics
NPI:1205036829
Name:ALLEN LAZERSON
Entity type:Organization
Organization Name:ALLEN LAZERSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAZERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:770-951-8976
Mailing Address - Street 1:1234 POWERS FERRY RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-9414
Mailing Address - Country:US
Mailing Address - Phone:770-951-8976
Mailing Address - Fax:770-951-8988
Practice Address - Street 1:1234 POWERS FERRY RD
Practice Address - Street 2:SUITE 103
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-9414
Practice Address - Country:US
Practice Address - Phone:770-951-8976
Practice Address - Fax:770-951-8988
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:A FAMILY PODIATRY CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-22
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000496332B00000X
GA000496213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00296458AMedicaid
GA00296458AMedicaid
GAT97715Medicare UPIN