Provider Demographics
NPI:1861558579
Name:LAWN, MARK JOHN (NEW YORK LIC OPHTHAL)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JOHN
Last Name:LAWN
Suffix:
Gender:M
Credentials:NEW YORK LIC OPHTHAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 EAST GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-4045
Mailing Address - Country:US
Mailing Address - Phone:315-253-2915
Mailing Address - Fax:315-258-8693
Practice Address - Street 1:13 EAST GENESEE ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-4045
Practice Address - Country:US
Practice Address - Phone:315-253-2915
Practice Address - Fax:315-258-8693
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC0031041156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
0527300001Medicare ID - Type Unspecified