Provider Demographics
NPI:1003390113
Name:BALTIERRA, LAUREN YOON (OD)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:YOON
Last Name:BALTIERRA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:MICHELLE
Other - Last Name:YOON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:22750 ALLEN RD
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:MI
Practice Address - Zip Code:48183-2246
Practice Address - Country:US
Practice Address - Phone:734-676-4300
Practice Address - Fax:734-676-5348
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005161152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist