Basic Information
| Provider Information | |||||||||
| NPI: | 1730255050 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LACKEY | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | MANNING | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1045 CENTRAL PARKWAY NORTH | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782325024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105414500 | ||||||||
| FaxNumber: | 2105414508 | ||||||||
| Practice Location | |||||||||
| Address1: | 2235 THOUSAND OAKS DR | ||||||||
| Address2: | SUITE #117 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782323966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104901000 | ||||||||
| FaxNumber: | 2104963590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 11/01/2012 | ||||||||
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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 | 207Q00000X | L5014 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 216649801 | 05 | TX | MEDICAID | 216649802 | 05 | TX | MEDICAID | Y29190 | 01 | TX | UPIN NUMBER | OTHER | L5014 | 01 | TX | TX LICENSE NUMBER | OTHER | 8CJ355 | 01 | TX | BLUECROSS BLUESHIELD | OTHER |