Basic Information
| Provider Information | |||||||||
| NPI: | 1174554646 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LACKMAN | ||||||||
| FirstName: | VERNON | ||||||||
| MiddleName: | HENRY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9602 | ||||||||
| Address2: | |||||||||
| City: | MISSION HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913469602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188375692 | ||||||||
| FaxNumber: | 8187924793 | ||||||||
| Practice Location | |||||||||
| Address1: | 17909 SOLEDAD CANYON RD | ||||||||
| Address2: | |||||||||
| City: | CANYON COUNTRY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913873210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612505244 | ||||||||
| FaxNumber: | 6612517308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 03/26/2014 | ||||||||
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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 | 207R00000X | G67735 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G677350 | 05 | CA | MEDICAID |