Provider Demographics
NPI:1073831376
Name:LANCASTER, JUSTIN RAY (IDC)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:RAY
Last Name:LANCASTER
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 OVERLAND TRL
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78410-1857
Mailing Address - Country:US
Mailing Address - Phone:619-379-4166
Mailing Address - Fax:
Practice Address - Street 1:5301 BAINBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-9026
Practice Address - Country:US
Practice Address - Phone:228-871-4158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-11
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman