1235299975 NPI number — JOHN LACUNZA M.D.

Table of content: JOHN LACUNZA M.D. (NPI 1235299975)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235299975 NPI number — JOHN LACUNZA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LACUNZA
Provider First Name:
JOHN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235299975
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 80070
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46898-0070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-432-1568
Provider Business Mailing Address Fax Number:
260-432-4969

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5001 US HIGHWAY 30 W STE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46818-9701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-432-1568
Provider Business Practice Location Address Fax Number:
260-432-4969
Provider Enumeration Date:
12/11/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  01063881A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085B0100X , with the licence number: 01063881A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200864150 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1235299975 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2786070 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".