Provider Demographics
NPI:1295707818
Name:LAUE, MICHAEL R (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:LAUE
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 1:6100 RONALD REAGAN BLVD.
Mailing Address - Street 2:
Mailing Address - City:LAKE ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367
Mailing Address - Country:US
Mailing Address - Phone:636-625-2143
Mailing Address - Fax:636-625-2148
Practice Address - Street 1:6100 RONALD REAGAN BLVD.
Practice Address - Street 2:
Practice Address - City:LAKE ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367
Practice Address - Country:US
Practice Address - Phone:636-625-2143
Practice Address - Fax:636-625-2148
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004016783152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO317192508Medicaid
MO1295707818Medicare NSC
MOV04102Medicare UPIN