1639173115 NPI number — DR. MARIO LUCERO MD

Table of content: DR. MARIO LUCERO MD (NPI 1639173115)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639173115 NPI number — DR. MARIO LUCERO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUCERO
Provider First Name:
MARIO
Provider Middle Name:
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:
1639173115
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/15/2006
NPI Reactivation Date:
04/04/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
ROUTE 16, MAIN STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAR
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
24892
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-425-1768
Provider Business Mailing Address Fax Number:
304-425-3912

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ROUTE 16, MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAR
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
24892
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-425-1768
Provider Business Practice Location Address Fax Number:
304-425-3912
Provider Enumeration Date:
06/13/2005

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: 171W00000X , with the licence number:  WV 13411 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 170100000X , with the licence number: WV13411 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0049852000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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