Basic Information
| Provider Information | |||||||||
| NPI: | 1235373135 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LACERNA | ||||||||
| FirstName: | CHARLTON | ||||||||
| MiddleName: | CASTILLO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 746723 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303746723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127339730 | ||||||||
| FaxNumber: | 7738668014 | ||||||||
| Practice Location | |||||||||
| Address1: | 11260 E JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482143320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137490148 | ||||||||
| FaxNumber: | 3132633298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2009 | ||||||||
| LastUpdateDate: | 03/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 60287621 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 4301116455 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.