1912189697 NPI number — ERNEST A. LUCERO, MD PC

Table of content: (NPI 1912189697)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912189697 NPI number — ERNEST A. LUCERO, MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ERNEST A. LUCERO, MD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1912189697
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6641 KANIKSU ST STE B
Provider Second Line Business Mailing Address:
PO BOX 898
Provider Business Mailing Address City Name:
BONNERS FERRY
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83805-7532
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-267-2086
Provider Business Mailing Address Fax Number:
208-267-4013

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6641 KANIKSU ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BONNERS FERRY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83805-7532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-267-2086
Provider Business Practice Location Address Fax Number:
208-267-4013
Provider Enumeration Date:
12/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LUCERO
Authorized Official First Name:
ERNEST
Authorized Official Middle Name:
ANTHONY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
208-267-2086

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  M5577 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DA558 . This is a "BLUE CROSS OF IDAHO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000010003687 . This is a "BLUE SHIELD OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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