Provider Demographics
NPI:1073590295
Name:LACY, CHRISTOPHER I (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:I
Last Name:LACY
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 1:1984 PEACHTREE RD NW
Mailing Address - Street 2:STE 505
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-5219
Mailing Address - Country:US
Mailing Address - Phone:770-779-2178
Mailing Address - Fax:
Practice Address - Street 1:11 UPPER RIVERDALE RD SW
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2615
Practice Address - Country:US
Practice Address - Phone:770-991-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0458652085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000799499Medicaid
GA30BDJCNMedicare PIN
GAG85435Medicare UPIN
GA30BDJPRMedicare PIN