Provider Demographics
NPI:1063499200
Name:LACERA, JACQUELYN V (MD)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:V
Last Name:LACERA
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21634 RETREAT PKWY
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92883-6100
Mailing Address - Country:US
Mailing Address - Phone:951-493-6906
Mailing Address - Fax:951-826-8157
Practice Address - Street 1:830 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3128
Practice Address - Country:US
Practice Address - Phone:951-493-6906
Practice Address - Fax:951-272-4839
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76173207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1730180415OtherGROUP NPI #
00A761731Medicare ID - Type Unspecified
1730180415OtherGROUP NPI #