Provider Demographics
NPI:1902861685
Name:LACK, DANIEL (OD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
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 1:117 PENSTOCK LN
Mailing Address - Street 2:
Mailing Address - City:LAKE KATRINE
Mailing Address - State:NY
Mailing Address - Zip Code:12449-5240
Mailing Address - Country:US
Mailing Address - Phone:845-336-6124
Mailing Address - Fax:
Practice Address - Street 1:117 PENSTOCK LN
Practice Address - Street 2:
Practice Address - City:LAKE KATRINE
Practice Address - State:NY
Practice Address - Zip Code:12449-5240
Practice Address - Country:US
Practice Address - Phone:845-336-6124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV003890152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01125268Medicaid
NYC35831Medicare ID - Type Unspecified
NY01125268Medicaid