Provider Demographics
NPI:1316941362
Name:LACONIC, MARY K (OD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:LACONIC
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 DOUGLAS DR N
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55429-3104
Mailing Address - Country:US
Mailing Address - Phone:763-537-3213
Mailing Address - Fax:763-537-6732
Practice Address - Street 1:5200 DOUGLAS DR N
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55429-3104
Practice Address - Country:US
Practice Address - Phone:763-537-3213
Practice Address - Fax:763-537-6732
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1674152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN749823300Medicaid
MN749823300Medicaid
MN410002209Medicare ID - Type Unspecified