Provider Demographics
NPI:1801882535
Name:LACK, MARY C (OD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:C
Last Name:LACK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 CONSERVATORY DR
Mailing Address - Street 2:
Mailing Address - City:BARBERTON
Mailing Address - State:OH
Mailing Address - Zip Code:44203-4281
Mailing Address - Country:US
Mailing Address - Phone:330-745-4404
Mailing Address - Fax:330-753-9162
Practice Address - Street 1:31 CONSERVATORY DR
Practice Address - Street 2:
Practice Address - City:BARBERTON
Practice Address - State:OH
Practice Address - Zip Code:44203-4281
Practice Address - Country:US
Practice Address - Phone:330-745-4404
Practice Address - Fax:330-753-9162
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4364152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH341904624OtherTRICARE
OH0266520001OtherADMINISTAR
OH54450OtherQUAL CHOICE
OH000000141886OtherANTHEM
OH2200676OtherUNITED HEALTH CARE
OH410041657OtherRAILROAD MEDICARE
OH341904624MLOtherSUMMA
OH0892155Medicaid
OH5521525OtherAETNA
OH54450OtherQUAL CHOICE
OH0720994Medicare ID - Type Unspecified