Provider Demographics
NPI:1891731055
Name:LUCAS, PHILLIP H (MD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:H
Last Name:LUCAS
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 1:136 EAST SPRING STREET
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-3208
Mailing Address - Country:US
Mailing Address - Phone:931-854-1011
Mailing Address - Fax:931-854-1335
Practice Address - Street 1:136 EAST SPRING STREET
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-3208
Practice Address - Country:US
Practice Address - Phone:931-854-1011
Practice Address - Fax:931-854-1335
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09840174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124463Medicaid
MSD32123Medicare UPIN
MS300000565Medicare ID - Type Unspecified