Provider Demographics
NPI:1013091347
Name:LASEK, EDMUND L JR
Entity Type:Individual
Prefix:MR
First Name:EDMUND
Middle Name:L
Last Name:LASEK
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502
Mailing Address - Country:US
Mailing Address - Phone:315-738-1754
Mailing Address - Fax:
Practice Address - Street 1:228 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502
Practice Address - Country:US
Practice Address - Phone:315-738-1754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4665156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01486488Medicaid
NY01486488Medicaid