Provider Demographics
NPI:1568656056
Name:LAKSANASUT, SUPATRA (OD)
Entity Type:Individual
Prefix:DR
First Name:SUPATRA
Middle Name:
Last Name:LAKSANASUT
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 1:1130 HIGHWAY 77
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08302-5988
Mailing Address - Country:US
Mailing Address - Phone:856-453-0418
Mailing Address - Fax:
Practice Address - Street 1:1130 HIGHWAY 77
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302-5988
Practice Address - Country:US
Practice Address - Phone:856-453-0418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00610200152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist