Provider Demographics
NPI:1467404301
Name:LUCAS, JAY LUKE (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:LUKE
Last Name:LUCAS
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 1:1540 AMERICAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505
Mailing Address - Country:US
Mailing Address - Phone:843-317-9999
Mailing Address - Fax:843-317-1996
Practice Address - Street 1:1540 AMERICAN DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-6072
Practice Address - Country:US
Practice Address - Phone:843-317-9999
Practice Address - Fax:843-317-1996
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9934174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC02-0654505OtherBLUE CROSS BLUE SHIELD
SCGP3611Medicaid
RI10-00541OtherCAROLINA CARE PLAN
SCD17923Medicare UPIN
SCGP3611Medicaid