Provider Demographics
NPI:1740450360
Name:MARK J LAWN OPTICIAN
Entity type:Organization
Organization Name:MARK J LAWN OPTICIAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:LAWN
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:315-253-2915
Mailing Address - Street 1:13 EAST GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-4095
Mailing Address - Country:US
Mailing Address - Phone:315-253-2915
Mailing Address - Fax:315-258-8693
Practice Address - Street 1:13 EAST GENESEE ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-4095
Practice Address - Country:US
Practice Address - Phone:315-253-2915
Practice Address - Fax:315-258-8693
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARK J LAWN OPTICIAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC0031041156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0527300001Medicare NSC