MEDICARE: LAI JIANG 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
1	152W00000X	Optometrist	3913-35	WI

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

General Provider Information

NPI Number	:	1790479996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAI JIANG OD

Provider Business Mailing Address
First Line	:	4847 E ROUTE 36
Second Line	:
City	:	DECATUR
State	:	IL
Zip	:	62521-9736
Country	:	US
Telephone Number	:	217-425-3219
Fax Number	:	217-425-3220

Provider Business Practice Location Address
First Line	:	1721 W MAIN ST
Second Line	:
City	:	SUN PRAIRIE
State	:	WI
Zip	:	53590-3161
Country	:	US
Telephone Number	:	608-837-7325
Fax Number	:

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

Provider Enumeration Date	:	06/08/2023
Last Update Date	:	02/25/2026

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Directions to “ LAI JIANG OD” Practice Location

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