Provider Demographics
NPI:1396585923
Name:LAMOINE, JACK MICHAEL (OD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:MICHAEL
Last Name:LAMOINE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2919 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-7527
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9117 LYNDALE AVE S
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-3522
Practice Address - Country:US
Practice Address - Phone:952-835-1235
Practice Address - Fax:952-835-1092
Is Sole Proprietor?:No
Enumeration Date:2024-05-30
Last Update Date:2025-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR390200000X152W00000X
COOPT.0004048152W00000X
MN4024152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist