Provider Demographics
NPI:1497728398
Name:LACKMAN, MICHAEL S (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:LACKMAN
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 1:65 DIVISION AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-2485
Mailing Address - Country:US
Mailing Address - Phone:541-689-1115
Mailing Address - Fax:541-688-5585
Practice Address - Street 1:65 DIVISION AVE
Practice Address - Street 2:SUITE E
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404-2485
Practice Address - Country:US
Practice Address - Phone:541-689-1115
Practice Address - Fax:541-688-5585
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1856ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR083019Medicaid
OR02501-01OtherPACIFIC SOURCE
OR111228OtherEYEMED
OR3021OtherNORTHWEST BENEFIT NETWORK
ORU16738Medicare UPIN
OR111228OtherEYEMED
OR1266170001Medicare NSC