Provider Demographics
NPI:1033195847
Name:POGUE, LUCAS C (MD)
Entity Type:Individual
Prefix:DR
First Name:LUCAS
Middle Name:C
Last Name:POGUE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3981
Mailing Address - Country:US
Mailing Address - Phone:309-663-8311
Mailing Address - Fax:309-661-3390
Practice Address - Street 1:1401 EASTLAND DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3552
Practice Address - Country:US
Practice Address - Phone:309-663-8311
Practice Address - Fax:309-661-3390
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103017208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036103017Medicaid
IL5715384OtherBLUE CROSS BLUE SHIELD
IL5715384OtherBLUE CROSS BLUE SHIELD
H60134Medicare UPIN
545260Medicare ID - Type Unspecified