Provider Demographics
NPI:1538119516
Name:LACK, MICHAEL DAVID (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:LACK
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 1:450 MARGARET ST
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-1755
Mailing Address - Country:US
Mailing Address - Phone:518-566-2020
Mailing Address - Fax:518-561-5390
Practice Address - Street 1:450 MARGARET ST
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-1755
Practice Address - Country:US
Practice Address - Phone:518-566-2020
Practice Address - Fax:518-561-5390
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV003563-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00568070Medicaid
J300033789Medicare PIN
NY00568070Medicaid