Provider Demographics
NPI:1033164645
Name:LUCERO, CARLOS ESTANISLAO (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:ESTANISLAO
Last Name:LUCERO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BECKLEY
Other - Middle Name:NEONATAL
Other - Last Name:PEDIATRIC CARE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DBA NAME
Mailing Address - Street 1:403 CARRIAGE DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-2805
Mailing Address - Country:US
Mailing Address - Phone:304-255-7456
Mailing Address - Fax:304-255-5899
Practice Address - Street 1:403 CARRIAGE DRIVE
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801
Practice Address - Country:US
Practice Address - Phone:304-255-7456
Practice Address - Fax:304-255-5899
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV103552080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0112021000Medicaid
WV0112021000Medicaid