Healthcare Provider Details

I. General information

NPI: 1295080596
Provider Name (Legal Business Name): LATASHA LAWRENCE O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2012
Last Update Date: 02/19/2026
Certification Date: 02/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

289 MAIN ST # L-2
EXTON PA
19341-3701
US

IV. Provider business mailing address

536 SW 24TH AVE
FORT LAUDERDALE FL
33312-2254
US

V. Phone/Fax

Practice location:
  • Phone: 484-875-9790
  • Fax: 610-884-4208
Mailing address:
  • Phone: 954-647-5475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG004328
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: