Provider Demographics
NPI:1114154283
Name:LACEY, BRENT W (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:W
Last Name:LACEY
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 1:4828 N DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2341
Mailing Address - Country:US
Mailing Address - Phone:850-477-8109
Mailing Address - Fax:850-478-2412
Practice Address - Street 1:100 BREWSTER BLVD
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-2575
Practice Address - Country:US
Practice Address - Phone:910-450-3841
Practice Address - Fax:910-450-3463
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME124361207RG0100X
TXN8314207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017169900Medicaid
FL4X7W3OtherBCBS
FLIO214ZOtherMCR