Provider Demographics
NPI:1043514607
Name:LAL, JEEVAK (MD)
Entity Type:Individual
Prefix:
First Name:JEEVAK
Middle Name:
Last Name:LAL
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 1:5887 N RICKFIELD RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-8314
Mailing Address - Country:US
Mailing Address - Phone:517-788-9932
Mailing Address - Fax:
Practice Address - Street 1:5887 N RICKFIELD RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-8314
Practice Address - Country:US
Practice Address - Phone:517-788-9932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-22
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301052150207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID83140Medicare UPIN