Provider Demographics
NPI:1093851164
Name:LUCERO, ROGER ALAN (MD)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:ALAN
Last Name:LUCERO
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 1:4001 W. DEVON AVE.
Mailing Address - Street 2:SUITE 207
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646
Mailing Address - Country:US
Mailing Address - Phone:773-930-4538
Mailing Address - Fax:773-930-4662
Practice Address - Street 1:4001 W DEVON AVE
Practice Address - Street 2:STE. 207
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-4523
Practice Address - Country:US
Practice Address - Phone:773-930-4538
Practice Address - Fax:773-930-4662
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36057435207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36-057435Medicaid
IL364377050-60004-01Medicaid
ILC43678Medicare UPIN
ILL81301Medicare UPIN
ILL80151Medicare ID - Type Unspecified
IL77248999781391Medicare PIN