Basic Information
| Provider Information | |||||||||
| NPI: | 1053799437 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LACEY | ||||||||
| FirstName: | ONTARIO | ||||||||
| MiddleName: | DEPREE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 612 ARTISAN RD | ||||||||
| Address2: | |||||||||
| City: | THOUSAND OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913205702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059535993 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 34800 BOB WILSON DR | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921343300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195329795 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2015 | ||||||||
| LastUpdateDate: | 05/18/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171000000X | Y | Other Service Providers | Military Health Care Provider |
No ID Information.