Provider Demographics
NPI:1154414027
Name:LUCERO, STEPHEN PAUL (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:PAUL
Last Name:LUCERO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 HOSPITAL DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4769
Mailing Address - Country:US
Mailing Address - Phone:505-989-8325
Mailing Address - Fax:505-982-7665
Practice Address - Street 1:1650 HOSPITAL DR
Practice Address - Street 2:SUITE 300
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4769
Practice Address - Country:US
Practice Address - Phone:505-989-8325
Practice Address - Fax:505-982-7665
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM 86 273208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ943384296OtherTAX ID
NM37481Medicaid
NJ943384296OtherTAX ID
NM37481Medicaid