Provider Demographics
NPI:1164584157
Name:FLAGEL, LAURIE L (OD)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:L
Last Name:FLAGEL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 S BREIEL BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45044-5104
Mailing Address - Country:US
Mailing Address - Phone:513-423-0941
Mailing Address - Fax:513-423-0840
Practice Address - Street 1:112 S BREIEL BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-5104
Practice Address - Country:US
Practice Address - Phone:513-423-0941
Practice Address - Fax:513-423-0840
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4906152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2330490Medicaid
OH0279240001Medicare NSC
OH9319901Medicare PIN
OH2330490Medicaid