Provider Demographics
NPI:1114955598
Name:LACKEY, THOMAS C II (D O)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:C
Last Name:LACKEY
Suffix:II
Gender:M
Credentials:D O
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4759 LAKEVIEW DR
Mailing Address - Street 2:STE 101
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33870-2005
Mailing Address - Country:US
Mailing Address - Phone:863-402-5600
Mailing Address - Fax:863-402-5602
Practice Address - Street 1:4759 LAKEVIEW DR
Practice Address - Street 2:STE 101
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-2005
Practice Address - Country:US
Practice Address - Phone:863-402-5600
Practice Address - Fax:863-402-5602
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2017-04-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS10031208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279537000Medicaid
FL279537000Medicaid