Individual
DR. MARY C LACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
OD
Contact information
Practice address
31 CONSERVATORY DR, BARBERTON, OH 44203-4281
(330) 745-4404
(330) 753-9162
Mailing address
31 CONSERVATORY DR, BARBERTON, OH 44203-4281
(330) 745-4404
(330) 753-9162
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
4364
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000141886
ANTHEM
OH
01
—
0266520001
ADMINISTAR
OH
05
—
0892155
—
OH
01
—
2200676
UNITED HEALTH CARE
OH
01
—
341904624
TRICARE
OH
01
—
341904624ML
SUMMA
OH
01
—
410041657
RAILROAD MEDICARE
OH
01
—
54450
QUAL CHOICE
OH
01
—
5521525
AETNA
OH
Enumeration date
09/27/2005
Last updated
04/08/2011
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