Basic Information
| Provider Information | |||||||||
| NPI: | 1740284389 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LACKEY | ||||||||
| FirstName: | VAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1227 N STATE ST | ||||||||
| Address2: | STE 101 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013552485 | ||||||||
| FaxNumber: | 6013531463 | ||||||||
| Practice Location | |||||||||
| Address1: | 1227 N STATE ST | ||||||||
| Address2: | STE 101 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013552485 | ||||||||
| FaxNumber: | 6013531463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2005 | ||||||||
| LastUpdateDate: | 06/18/2010 | ||||||||
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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 | 207RH0003X | 06430 | MS | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RX0202X | 06430 | MS | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 4285654 | 01 | AETNA HEALTHCARE | OTHER | 00115429 | 05 | MS | MEDICAID | 1541575 | 05 | LA | MEDICAID |