Provider Demographics
NPI:1962414706
Name:LACEY, JOSEPH RANDALL (OD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:RANDALL
Last Name:LACEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16306 E LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78734-1132
Mailing Address - Country:US
Mailing Address - Phone:512-263-0020
Mailing Address - Fax:512-263-4623
Practice Address - Street 1:12700 HILL COUNTRY BLVD
Practice Address - Street 2:SUITE S-110
Practice Address - City:BEE CAVE
Practice Address - State:TX
Practice Address - Zip Code:78738-6361
Practice Address - Country:US
Practice Address - Phone:512-263-0020
Practice Address - Fax:512-263-4623
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2356TG152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81045EMedicare ID - Type UnspecifiedINDIVIDUAL PROVIDER NO.
TXT14308Medicare UPIN