Basic Information
| Provider Information | |||||||||
| NPI: | 1053422238 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUCAS | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | LEROY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5719 | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306045719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063545770 | ||||||||
| FaxNumber: | 7063545769 | ||||||||
| Practice Location | |||||||||
| Address1: | 2450 S TELSHOR BLVD | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880115069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063545770 | ||||||||
| FaxNumber: | 7063545769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 03/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 2021007445 | MO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | MD 2009-0058 | NM | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 110287 | MO | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 71229558 | 05 | NM | MEDICAID |