Provider Demographics
NPI:1790750750
Name:BURCH, LAN F (OD)
Entity Type:Individual
Prefix:
First Name:LAN
Middle Name:F
Last Name:BURCH
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 1:201 S AVALON ST
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-4172
Mailing Address - Country:US
Mailing Address - Phone:870-732-4701
Mailing Address - Fax:870-732-5400
Practice Address - Street 1:201 S AVALON ST
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-4172
Practice Address - Country:US
Practice Address - Phone:870-732-4701
Practice Address - Fax:870-732-5400
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2025152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR101945722Medicaid
48683Medicare ID - Type Unspecified
AR0372520001Medicare NSC
T20221Medicare UPIN