Provider Demographics
NPI:1073975181
Name:LUCAS, KRISTIN (MD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:LUCAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:
Other - Last Name:LITTLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:31 W 155TH ST
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:IL
Mailing Address - Zip Code:60426-3556
Mailing Address - Country:US
Mailing Address - Phone:708-596-5177
Mailing Address - Fax:708-596-5518
Practice Address - Street 1:31 W 155TH ST
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-3556
Practice Address - Country:US
Practice Address - Phone:708-596-5177
Practice Address - Fax:708-596-5518
Is Sole Proprietor?:No
Enumeration Date:2016-03-28
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.068797208000000X
IL036151537208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036151537Medicaid