Provider Demographics
NPI:1255409066
Name:OPTOMETRY PC
Entity type:Organization
Organization Name:OPTOMETRY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:LAKIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:586-263-9708
Mailing Address - Street 1:21701 KELLY RD
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021
Mailing Address - Country:US
Mailing Address - Phone:586-779-4200
Mailing Address - Fax:586-779-6115
Practice Address - Street 1:21701 KELLY RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021
Practice Address - Country:US
Practice Address - Phone:586-779-4200
Practice Address - Fax:586-779-6115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOE06315OtherHAP
MI230460OtherNVA
MIOE06315OtherHAP
MI0E06315Medicare PIN