Provider Demographics
NPI:1306560024
Name:LUCAS, DEMETRIOUS D (CM)
Entity type:Individual
Prefix:
First Name:DEMETRIOUS
Middle Name:D
Last Name:LUCAS
Suffix:
Gender:M
Credentials:CM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 DODGE CT APT A
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:OH
Mailing Address - Zip Code:45431-4886
Mailing Address - Country:US
Mailing Address - Phone:937-248-7068
Mailing Address - Fax:
Practice Address - Street 1:2611 WAYNE AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45420-1833
Practice Address - Country:US
Practice Address - Phone:937-228-0579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator