Provider Demographics
NPI:1275523680
Name:LASSEN, RAY A (OD)
Entity Type:Individual
Prefix:DR
First Name:RAY
Middle Name:A
Last Name:LASSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:1 OAK TREE VLG
Mailing Address - Street 2:STE 200
Mailing Address - City:DONIPHAN
Mailing Address - State:MO
Mailing Address - Zip Code:63935-1901
Mailing Address - Country:US
Mailing Address - Phone:573-996-7529
Mailing Address - Fax:573-996-4162
Practice Address - Street 1:1 OAK TREE VLG
Practice Address - Street 2:STE 200
Practice Address - City:DONIPHAN
Practice Address - State:MO
Practice Address - Zip Code:63935-1901
Practice Address - Country:US
Practice Address - Phone:573-996-7529
Practice Address - Fax:573-996-4162
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2010-06-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MOT02728152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO312537103Medicaid
MO108471OtherBLUE CROSS & BLUE SHIELD
MO000009316Medicare PIN
MO312537103Medicaid
MOT93151Medicare UPIN