Provider Demographics
NPI:1033314984
Name:LACKEY, WESLEY GRAYSON (MD)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:GRAYSON
Last Name:LACKEY
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 1:3600 W BETHEL AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-5407
Mailing Address - Country:US
Mailing Address - Phone:800-622-6575
Mailing Address - Fax:
Practice Address - Street 1:6920 GATWICK DR
Practice Address - Street 2:SUITE 200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-9504
Practice Address - Country:US
Practice Address - Phone:317-455-1064
Practice Address - Fax:317-455-1204
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL29757207X00000X
IN01071508A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1033314984OtherNPI