Provider Demographics
NPI:1235128414
Name:LACY, ROBERT T (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:T
Last Name:LACY
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 1:696 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:SO. WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190
Mailing Address - Country:US
Mailing Address - Phone:781-331-3300
Mailing Address - Fax:781-337-8356
Practice Address - Street 1:696 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SO. WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190
Practice Address - Country:US
Practice Address - Phone:781-331-3300
Practice Address - Fax:781-337-8356
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA32765207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA032765OtherTUFTS
MA110035543AMedicaid
MA15069OtherHARVARD PILGRIM
A40120Medicare UPIN
MAB11351Medicare ID - Type Unspecified