Provider Demographics
NPI:1871121780
Name:LAZZARA, MATTHEW VINCENT
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:VINCENT
Last Name:LAZZARA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 BROOKER CREEK BLVD STE 215
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-2937
Mailing Address - Country:US
Mailing Address - Phone:813-854-2003
Mailing Address - Fax:813-436-5378
Practice Address - Street 1:3638 MADACA LN
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2057
Practice Address - Country:US
Practice Address - Phone:813-968-6610
Practice Address - Fax:813-264-1669
Is Sole Proprietor?:No
Enumeration Date:2020-03-28
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME164138208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics