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NPI Code Detail

MEDICARE: MARY K LACONIC OD

MEDICARE: MARY K LACONIC OD
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
1152W00000XOptometrist1674MN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1316941362
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARY K LACONIC OD
Provider Business Mailing Address
First Line : 5200 DOUGLAS DR N
Second Line :
City : CRYSTAL
State : MN
Zip : 55429-3104
Country : US
Telephone Number : 763-537-3213
Fax Number : 763-537-6732
Provider Business Practice Location Address
First Line : 5200 DOUGLAS DR N
Second Line :
City : CRYSTAL
State : MN
Zip : 55429-3104
Country : US
Telephone Number : 763-537-3213
Fax Number : 763-537-6732
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/08/2005
Last Update Date : 06/29/2011

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