Provider Demographics
NPI:1093762098
Name:LUCAS, KENNETH G (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:G
Last Name:LUCAS
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 1:33 LEWIS RD
Mailing Address - Street 2:2ND FL
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905
Mailing Address - Country:US
Mailing Address - Phone:607-729-8156
Mailing Address - Fax:
Practice Address - Street 1:179 RIVER ST
Practice Address - Street 2:
Practice Address - City:ONEONTA
Practice Address - State:NY
Practice Address - Zip Code:13820-2239
Practice Address - Country:US
Practice Address - Phone:607-433-3484
Practice Address - Fax:607-432-5790
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1887262080P0207X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012617180002Medicaid
F07520Medicare UPIN
PA699552Medicare ID - Type Unspecified
PA0012617180002Medicaid