Provider Demographics
NPI:1285625640
Name:LACKEY, CHARLES LEE (MD)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:LEE
Last Name:LACKEY
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 1:1515 N PORTER AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-6649
Mailing Address - Country:US
Mailing Address - Phone:405-366-8619
Mailing Address - Fax:
Practice Address - Street 1:1515 N PORTER AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-6649
Practice Address - Country:US
Practice Address - Phone:405-366-8619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12222207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100106340AMedicaid
OKC95149Medicare UPIN