Provider Demographics
NPI:1295920973
Name:LASSA, LAWRENCE DAVID (OD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:DAVID
Last Name:LASSA
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 1:420 N GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-5156
Mailing Address - Country:US
Mailing Address - Phone:432-332-9920
Mailing Address - Fax:432-337-8833
Practice Address - Street 1:420 N GRANT AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5156
Practice Address - Country:US
Practice Address - Phone:432-332-9920
Practice Address - Fax:432-337-8833
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3653TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT92020Medicare UPIN