Provider Demographics
NPI:1366478653
Name:WILEY-LUCAS, THELMA E (MD)
Entity Type:Individual
Prefix:
First Name:THELMA
Middle Name:E
Last Name:WILEY-LUCAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 CLINIC AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4454
Mailing Address - Country:US
Mailing Address - Phone:770-214-2800
Mailing Address - Fax:770-214-2803
Practice Address - Street 1:157 CLINIC AVE STE 201
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4454
Practice Address - Country:US
Practice Address - Phone:770-214-2800
Practice Address - Fax:770-214-2803
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058487207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA179173719AMedicaid
GAP00384988OtherRAIL ROAD MEDICARE
GAG16540Medicare UPIN
GA10BDHKXMedicare PIN