Provider Demographics
NPI:1023898566
Name:LAZO, MAYRA CAROLINA (OD)
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:CAROLINA
Last Name:LAZO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15243 CANTLAY ST
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-2002
Mailing Address - Country:US
Mailing Address - Phone:818-445-6816
Mailing Address - Fax:
Practice Address - Street 1:6765 LANKERSHIM BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-1614
Practice Address - Country:US
Practice Address - Phone:818-982-0076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35599152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist