Provider Demographics
NPI:1922060888
Name:RUNNERSTROM, LAURIE A (OD)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:A
Last Name:RUNNERSTROM
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 1:99 TROY RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:EAST GREENBUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12061-1027
Mailing Address - Country:US
Mailing Address - Phone:518-479-3306
Mailing Address - Fax:518-479-4502
Practice Address - Street 1:99 TROY RD STE 201
Practice Address - Street 2:
Practice Address - City:EAST GREENBUSH
Practice Address - State:NY
Practice Address - Zip Code:12061-1027
Practice Address - Country:US
Practice Address - Phone:518-479-3306
Practice Address - Fax:518-479-4502
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTU006627-1152W00000X
IL046-008328152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U36146Medicare UPIN
U36146Medicare UPIN