MEDICARE: DR. MICHAEL S. LACKMAN O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1856ATI	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	02501-01	OTHER	OR	PACIFIC SOURCE
3	111228	OTHER	OR	EYEMED
4	3021	OTHER	OR	NORTHWEST BENEFIT NETWORK

General Provider Information

NPI Number	:	1497728398
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL S. LACKMAN O.D.

Provider Business Mailing Address
First Line	:	65 DIVISION AVE
Second Line	:	SUITE E
City	:	EUGENE
State	:	OR
Zip	:	97404-2485
Country	:	US
Telephone Number	:	541-689-1115
Fax Number	:	541-688-5585

Provider Business Practice Location Address
First Line	:	65 DIVISION AVE
Second Line	:	SUITE E
City	:	EUGENE
State	:	OR
Zip	:	97404-2485
Country	:	US
Telephone Number	:	541-689-1115
Fax Number	:	541-688-5585

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/10/2006
Last Update Date	:	10/10/2007

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