Provider Demographics
NPI:1295232643
Name:LUCAS, TYLER JACOB (DO)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:JACOB
Last Name:LUCAS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 SATORI PKWY STE 120
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-6407
Mailing Address - Country:US
Mailing Address - Phone:317-718-4863
Mailing Address - Fax:317-272-7855
Practice Address - Street 1:301 SATORI PKWY STE 120
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-6407
Practice Address - Country:US
Practice Address - Phone:317-718-4263
Practice Address - Fax:317-272-7855
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11019906A207Q00000X
IN02006385A207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine