Basic Information
Provider Information | |||||||||
NPI: | 1366450041 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LYSIUK | ||||||||
FirstName: | LANCE | ||||||||
MiddleName: | CALL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | OD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 888 WORCESTER ST | ||||||||
Address2: | SUITE 130 | ||||||||
City: | WELLESLEY | ||||||||
State: | MA | ||||||||
PostalCode: | 024823744 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6179646681 | ||||||||
FaxNumber: | 3396862561 | ||||||||
Practice Location | |||||||||
Address1: | 438 MAIN ST | ||||||||
Address2: | SUITE 204 | ||||||||
City: | MIDDLETOWN | ||||||||
State: | CT | ||||||||
PostalCode: | 064573396 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8889646681 | ||||||||
FaxNumber: | 8886620859 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/04/2006 | ||||||||
LastUpdateDate: | 10/24/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 002499 | CT | Y |   | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 004189868 | 05 | CT |   | MEDICAID | 090002499CT01 | 01 | CT | BLUE CROSS BLUE SHIELD | OTHER | 410038928 | 01 | CT | MEDICARE RAILROAD | OTHER |