Provider Demographics
NPI:1164457081
Name:LACEY, JAMES PETER (MD)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:PETER
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-298-0797
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:1223 GATEWAY DR STE 1E
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-729-8079
Practice Address - Fax:321-984-8483
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME141937207Y00000X
CAA81368207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103767400Medicaid
FLLN872OtherMEDICARE
FLM7508OtherMEDICARE