Provider Demographics
NPI:1144226291
Name:LACKEY, CHARLES WARREN (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:WARREN
Last Name:LACKEY
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 1:822 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LEADVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80461-3861
Mailing Address - Country:US
Mailing Address - Phone:719-486-1264
Mailing Address - Fax:
Practice Address - Street 1:822 W 4TH ST
Practice Address - Street 2:
Practice Address - City:LEADVILLE
Practice Address - State:CO
Practice Address - Zip Code:80461-3861
Practice Address - Country:US
Practice Address - Phone:719-486-1264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO19438207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01194380Medicaid
D23606Medicare UPIN
G6248Medicare ID - Type Unspecified