Provider Demographics
NPI:1114196169
Name:LACIAK, ROBERT JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JOHN
Last Name:LACIAK
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:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:990 NW CIRCLE BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-1967
Practice Address - Country:US
Practice Address - Phone:541-768-5486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6851346-1205208800000X
ORMD152679208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology