Provider Demographics
NPI:1366450041
Name:LYSIUK, LANCE CALL (OD)
Entity Type:Individual
Prefix:DR
First Name:LANCE
Middle Name:CALL
Last Name:LYSIUK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:888 WORCESTER ST
Mailing Address - Street 2:SUITE 130
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-3744
Mailing Address - Country:US
Mailing Address - Phone:617-964-6681
Mailing Address - Fax:339-686-2561
Practice Address - Street 1:438 MAIN ST
Practice Address - Street 2:SUITE 204
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3396
Practice Address - Country:US
Practice Address - Phone:888-964-6681
Practice Address - Fax:888-662-0859
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2014-10-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CT002499152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004189868Medicaid
CT090002499CT01OtherBLUE CROSS BLUE SHIELD
CT410038928OtherMEDICARE RAILROAD
CT004189868Medicaid
CT410038928OtherMEDICARE RAILROAD