Provider Demographics
NPI:1376732388
Name:LAKE LAZER EYE CENTER
Entity Type:Organization
Organization Name:LAKE LAZER EYE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PREIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHABBIR
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAMBATI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-792-3891
Mailing Address - Street 1:44000 W 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-2644
Mailing Address - Country:US
Mailing Address - Phone:586-792-3891
Mailing Address - Fax:
Practice Address - Street 1:44000 W 12 MILE RD
Practice Address - Street 2:SUITE 112
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2644
Practice Address - Country:US
Practice Address - Phone:586-792-3891
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE LAZER EYE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-16
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISK070791305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIH42351OtherHAP
MI0501160OtherBLUE CARE NETWORK
MI140631OtherGREAT LAKES
MI4606945Medicaid
MI0501160OtherBLUE CROSS BLUE SHIELD
MI0501160OtherBLUE CARE NETWORK
MI0N32640Medicare PIN
MI4606945Medicaid