Healthcare Provider Details

I. General information

NPI: 1063544484
Provider Name (Legal Business Name): LANSING OPHTHALMOLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E MICHIGAN AVE SUITE 110
LANSING MI
48912-1800
US

IV. Provider business mailing address

1005 CHARLEVOIX DR STE 100
GRAND LEDGE MI
48837-8186
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-5875
  • Fax: 517-364-5877
Mailing address:
  • Phone: 517-337-1668
  • Fax: 517-622-1205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: DONALD SHOOK
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 517-337-1899