Provider Demographics
NPI:1508853870
Name:LASTINGER, NORMAN LYLE (OD)
Entity Type:Individual
Prefix:
First Name:NORMAN
Middle Name:LYLE
Last Name:LASTINGER
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:PO BOX 670
Mailing Address - Street 2:
Mailing Address - City:BARNESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30204-0670
Mailing Address - Country:US
Mailing Address - Phone:770-358-1010
Mailing Address - Fax:770-358-9132
Practice Address - Street 1:641 HIGHWAY 341 S
Practice Address - Street 2:
Practice Address - City:BARNESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30204-1555
Practice Address - Country:US
Practice Address - Phone:770-358-1010
Practice Address - Fax:770-358-9132
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001094152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4016810001OtherCMS - MEDICARE SUPPLIER #
GA000357926-GMedicaid
GAU22330Medicare UPIN
GA41ZCBZJMedicare ID - Type Unspecified