Provider Demographics
NPI:1295909398
Name:LANTZ, MARK WAYNE (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:WAYNE
Last Name:LANTZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2555 PHILLIPS FIELD RD
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-3933
Mailing Address - Country:US
Mailing Address - Phone:907-328-2980
Mailing Address - Fax:907-456-2914
Practice Address - Street 1:2555 PHILLIPS FIELD RD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-3933
Practice Address - Country:US
Practice Address - Phone:907-328-2980
Practice Address - Fax:907-456-2914
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1934DT152W00000X
MI4901004481152W00000X
AK171851152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900A210610OtherBCBSM