Provider Demographics
NPI:1972583037
Name:LASOVAGE, WALTER J (OD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:J
Last Name:LASOVAGE
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 1:24911 NEWTON ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1557
Mailing Address - Country:US
Mailing Address - Phone:313-204-8018
Mailing Address - Fax:989-725-6055
Practice Address - Street 1:311 E MAIN ST
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-3136
Practice Address - Country:US
Practice Address - Phone:989-725-2311
Practice Address - Fax:989-725-6055
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2601152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0838030001Medicare NSC
MI33610Medicare UPIN
MIOM89160001Medicare ID - Type UnspecifiedMEDICARE