Basic Information
| Provider Information | |||||||||
| NPI: | 1962401968 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOUCKS | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | LAMAR | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323084646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8502160100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1300 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323084646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8502160100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2005 | ||||||||
| LastUpdateDate: | 06/07/2012 | ||||||||
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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 | 207R00000X | ME27009 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00000 | 01 | FL | BEECHST/CAPP CARE | OTHER | 00000 | 01 | FL | EVOLUTIONS | OTHER | 000000 | 01 | FL | UNIVERSAL HEALTH CARE | OTHER | 057262400 | 05 | FL | MEDICAID | 37222 | 01 | FL | BCBSFL | OTHER | 00134945A | 05 | GA | MEDICAID | 00000 | 01 | FL | NOVANET | OTHER | 00000 | 01 | FL | UNITEDHEALTH CARE | OTHER | 00000 | 01 | FL | CAPITAL HEALTH PLAN | OTHER | 00000 | 01 | FL | SOUTHCARE | OTHER |