Provider Demographics
NPI:1093758708
Name:LACY, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
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:PO BOX 6388
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90734-6388
Mailing Address - Country:US
Mailing Address - Phone:310-225-3244
Mailing Address - Fax:310-698-7054
Practice Address - Street 1:24451 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3689
Practice Address - Country:US
Practice Address - Phone:949-452-3050
Practice Address - Fax:949-452-3066
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79003207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G790030Medicaid
CAG53150Medicare UPIN
CAWG79003HMedicare PIN
CAWG79003AMedicare PIN
CAWG79003EMedicare PIN
CAWG79003FMedicare PIN
CA00G790030Medicaid
CAWG79003CMedicare PIN
CAWG79003DMedicare PIN