Basic Information
| Provider Information | |||||||||
| NPI: | 1053476085 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LACZKOWSKI | ||||||||
| FirstName: | JOHN | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11103 WEST AVE | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782131370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105246663 | ||||||||
| FaxNumber: | 2105246587 | ||||||||
| Practice Location | |||||||||
| Address1: | 2761 S 108TH ST | ||||||||
| Address2: | |||||||||
| City: | WEST ALLIS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532273232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143212425 | ||||||||
| FaxNumber: | 4143214647 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1430-035 | WI | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 38502300 | 05 | WI | MEDICAID |