Provider Demographics
NPI:1265568406
Name:LACKORE, PAUL M (OD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:M
Last Name:LACKORE
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 1:1437 N WEBB RD
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-2313
Mailing Address - Country:US
Mailing Address - Phone:308-382-9205
Mailing Address - Fax:308-382-3414
Practice Address - Street 1:1437 N WEBB RD
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-2313
Practice Address - Country:US
Practice Address - Phone:308-382-9205
Practice Address - Fax:308-382-3414
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1004152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE6937OtherBLUE CROSS
U08418Medicare UPIN
266876Medicare ID - Type Unspecified