Provider Demographics
NPI:1326130725
Name:LACERNA, MARIO DANTE (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:DANTE
Last Name:LACERNA
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 1:3621 SOUTH STATE STREET
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:1501 W CHISHOLM ST
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1401
Practice Address - Country:US
Practice Address - Phone:888-356-7151
Practice Address - Fax:989-356-8117
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010595922085R0001X
FLME1115952085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4303114Medicaid
FL4375200Medicaid
FLFT108YOtherMEDICARE
MIG51639Medicare UPIN
MI0M50620025Medicare ID - Type Unspecified