Provider Demographics
NPI:1417923244
Name:LACEY, HEIDI LYNN (OD)
Entity Type:Individual
Prefix:DR
First Name:HEIDI
Middle Name:LYNN
Last Name:LACEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:283 STADIUM DR
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-4604
Mailing Address - Country:US
Mailing Address - Phone:419-782-3937
Mailing Address - Fax:419-782-3930
Practice Address - Street 1:283 STADIUM DR
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-4604
Practice Address - Country:US
Practice Address - Phone:419-782-3937
Practice Address - Fax:419-782-3930
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5437152W00000X
IN18003262A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0051320Medicaid
H014220Medicare PIN
V05321Medicare UPIN