Provider Demographics
NPI:1841218518
Name:MASOPUST, LENA CYNTHIA (OD)
Entity Type:Individual
Prefix:
First Name:LENA
Middle Name:CYNTHIA
Last Name:MASOPUST
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11103 WEST AVE
Mailing Address - Street 2:6
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1370
Mailing Address - Country:US
Mailing Address - Phone:210-524-6663
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:2100 PLEASANT HILL RD
Practice Address - Street 2:H10-1
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-4701
Practice Address - Country:US
Practice Address - Phone:678-475-0500
Practice Address - Fax:678-475-0563
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001453152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU71044Medicare UPIN