Provider Demographics
NPI:1164911095
Name:LUCERO, RAYMUND (PT)
Entity Type:Individual
Prefix:
First Name:RAYMUND
Middle Name:
Last Name:LUCERO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3856 N BUTLER AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-2366
Mailing Address - Country:US
Mailing Address - Phone:407-461-7023
Mailing Address - Fax:
Practice Address - Street 1:1101 W MURRAY DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-3845
Practice Address - Country:US
Practice Address - Phone:505-326-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4329208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation