Provider Demographics
NPI:1639198203
Name:LACEY, ROBERT RAY (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:RAY
Last Name:LACEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:ROBERT
Other - Middle Name:RAY
Other - Last Name:LACEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:207 W COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:MS
Mailing Address - Zip Code:39730-2633
Mailing Address - Country:US
Mailing Address - Phone:662-369-9020
Mailing Address - Fax:662-369-9810
Practice Address - Street 1:207 W COMMERCE ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:MS
Practice Address - Zip Code:39730-2633
Practice Address - Country:US
Practice Address - Phone:662-369-9020
Practice Address - Fax:662-369-9810
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS403152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880116Medicaid
0965560001Medicare NSC
MST21112Medicare UPIN
560816275Medicare ID - Type Unspecified