Provider Demographics
NPI:1548267594
Name:LAWRENCE, JACK D JR (OD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:D
Last Name:LAWRENCE
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:150 MARKET HILLS DR
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-3678
Mailing Address - Country:US
Mailing Address - Phone:828-262-1554
Mailing Address - Fax:828-268-2981
Practice Address - Street 1:150 MARKET HILLS DR
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-3678
Practice Address - Country:US
Practice Address - Phone:828-262-1554
Practice Address - Fax:828-268-2981
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0889152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89-09519Medicaid
09519OtherBCBS
NC246223Medicare PIN
NC89-09519Medicaid