Provider Demographics
NPI:1174501985
Name:LAZERSON, JACK (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:LAZERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 W CHARLESTON BLVD
Mailing Address - Street 2:202-A
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-2227
Mailing Address - Country:US
Mailing Address - Phone:702-671-2355
Mailing Address - Fax:702-382-5388
Practice Address - Street 1:1524 PINTO LN
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4195
Practice Address - Country:US
Practice Address - Phone:702-671-2231
Practice Address - Fax:702-671-2233
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5408208000000X, 2080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002019718Medicaid
NVCS04078OtherSTATE PHARMACY
NVCS04078OtherSTATE PHARMACY
NVCS04078OtherSTATE PHARMACY
NV002019718Medicaid