1730255050 NPI number — DR. JAMES MANNING LACKEY MD

Table of content: DR. JAMES MANNING LACKEY MD (NPI 1730255050)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730255050 NPI number — DR. JAMES MANNING LACKEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LACKEY
Provider First Name:
JAMES
Provider Middle Name:
MANNING
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1730255050
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1045 CENTRAL PARKWAY NORTH
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78232-5024
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-541-4500
Provider Business Mailing Address Fax Number:
210-541-4508

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2235 THOUSAND OAKS DR
Provider Second Line Business Practice Location Address:
SUITE #117
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78232-3966
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-490-1000
Provider Business Practice Location Address Fax Number:
210-496-3590
Provider Enumeration Date:
11/28/2006

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: 207Q00000X , with the licence number:  L5014 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 216649801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 216649802 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: Y29190 . This is a "UPIN NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: L5014 . This is a "TX LICENSE NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8CJ355 . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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