Provider Demographics
NPI:1114951951
Name:MOTACEK, LAWRENCE J (OD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:J
Last Name:MOTACEK
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 1:300 2ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401
Mailing Address - Country:US
Mailing Address - Phone:701-252-2020
Mailing Address - Fax:701-251-2801
Practice Address - Street 1:300 2ND AVE NE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401
Practice Address - Country:US
Practice Address - Phone:701-252-2020
Practice Address - Fax:701-251-2801
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND486152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND2200303OtherMEDICA
ND01013875OtherPREFERRED ONE
ND60463Medicaid
ND0255160001OtherCIGNA MEDICARE
ND870486OtherNOVSI
ND410030693OtherTRAVELERS MEDICARE
ND410030693OtherTRAVELERS MEDICARE
U44192Medicare UPIN