Provider Demographics
NPI:1053476085
Name:LACZKOWSKI, JOHN (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:LACZKOWSKI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11103 WEST AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1370
Mailing Address - Country:US
Mailing Address - Phone:210-524-6663
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:2761 S 108TH ST
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-3232
Practice Address - Country:US
Practice Address - Phone:414-321-2425
Practice Address - Fax:414-321-4647
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1430-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38502300Medicaid
WI38502300Medicaid