Provider Demographics
NPI:1730169343
Name:LAZAROFF, JERRY M (PHD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:M
Last Name:LAZAROFF
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1029 N PROVIDENCE RD
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-1404
Mailing Address - Country:US
Mailing Address - Phone:610-566-6633
Mailing Address - Fax:610-566-6637
Practice Address - Street 1:1029 N PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-1404
Practice Address - Country:US
Practice Address - Phone:610-566-6633
Practice Address - Fax:610-566-6637
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-002867-L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1155OtherPA BLUE SHIELD
001155Medicare ID - Type Unspecified
R05281Medicare UPIN