Provider Demographics
NPI:1346592680
Name:GENEREUX, LUCAS K (OD)
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:K
Last Name:GENEREUX
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 1:1611 ANNE ST NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5114
Mailing Address - Country:US
Mailing Address - Phone:218-333-2020
Mailing Address - Fax:
Practice Address - Street 1:1611 ANNE ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5114
Practice Address - Country:US
Practice Address - Phone:218-333-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-10
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN3425152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400224111Medicare PIN
MNH400224109Medicare PIN
MNH400224118Medicare PIN