Basic Information
| Provider Information | |||||||||
| NPI: | 1073564829 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LACY | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | LAMONT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1990 INDUSTRIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703637055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858689300 | ||||||||
| FaxNumber: | 9858510053 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 HOWARD AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037852815 | ||||||||
| FaxNumber: | 2037854043 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 07/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 15489R | LA | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 71573 | CT | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 2336495 | 05 | LA | MEDICAID |