Provider Demographics
NPI:1215554092
Name:LASKOVICH, ZACHARY EDWARD (OD)
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:EDWARD
Last Name:LASKOVICH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3409 N ANTHONY BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-2233
Mailing Address - Country:US
Mailing Address - Phone:765-617-1890
Mailing Address - Fax:260-484-0616
Practice Address - Street 1:3409 N ANTHONY BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-2233
Practice Address - Country:US
Practice Address - Phone:765-617-1890
Practice Address - Fax:260-484-0616
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004220A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist