Provider Demographics
NPI:1013171743
Name:BOGGS, LACY ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:LACY
Middle Name:ANN
Last Name:BOGGS
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 1:112 W WASHINGTON ST
Mailing Address - Street 2:STE 101
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-2590
Mailing Address - Country:US
Mailing Address - Phone:765-484-8247
Mailing Address - Fax:765-484-8253
Practice Address - Street 1:112 W WASHINGTON ST
Practice Address - Street 2:STE 101
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-2590
Practice Address - Country:US
Practice Address - Phone:765-484-8247
Practice Address - Fax:765-484-8253
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-11
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5808152W00000X
IN18003549152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist