Provider Demographics
NPI:1992753883
Name:LACQUA, MICHAEL JUDE (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JUDE
Last Name:LACQUA
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 1:2372 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6607
Mailing Address - Country:US
Mailing Address - Phone:718-761-3700
Mailing Address - Fax:
Practice Address - Street 1:2372 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6607
Practice Address - Country:US
Practice Address - Phone:718-761-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY192446208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01710118Medicaid
NYF93944Medicare UPIN
NY01710118Medicaid