Provider Demographics
NPI:1346381373
Name:LANE, LAURA SUZANNE (OD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:SUZANNE
Last Name:LANE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:MASTERS
Other - Last Name:KOON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:4325 MILLER RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-1216
Mailing Address - Country:US
Mailing Address - Phone:810-230-9292
Mailing Address - Fax:810-230-7841
Practice Address - Street 1:4325 MILLER RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507
Practice Address - Country:US
Practice Address - Phone:810-230-9292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-11
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003727152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN26930148Medicare PIN
MIU73525Medicare UPIN