Provider Demographics
NPI:1285693911
Name:LACKSEN, FELICIA S (MD)
Entity type:Individual
Prefix:DR
First Name:FELICIA
Middle Name:S
Last Name:LACKSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 PACES FERRY ROAD
Mailing Address - Street 2:SUITE 1-1100 (ATTENTION DENISE)
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339
Mailing Address - Country:US
Mailing Address - Phone:470-271-3421
Mailing Address - Fax:
Practice Address - Street 1:1351 STONEBRIDGE PKWY
Practice Address - Street 2:BLDG 105
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-6037
Practice Address - Country:US
Practice Address - Phone:706-769-3331
Practice Address - Fax:706-769-3360
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047612207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00857007AMedicaid
11BDRHMMedicare ID - Type Unspecified
G51901Medicare UPIN