Provider Demographics
NPI:1700992203
Name:SIDER, LAWRENCE (OD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:
Last Name:SIDER
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 1:2200 GLADES RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-7309
Mailing Address - Country:US
Mailing Address - Phone:561-226-4920
Mailing Address - Fax:561-988-9325
Practice Address - Street 1:2200 GLADES RD
Practice Address - Street 2:SUITE 105
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-7309
Practice Address - Country:US
Practice Address - Phone:561-226-4920
Practice Address - Fax:561-988-9325
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2013-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1693152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK7007Medicare ID - Type UnspecifiedGROUP #
FLT54778Medicare UPIN
FL20254BMedicare PIN