Provider Demographics
NPI:1508877630
Name:LACOSTE, CLEMENT EMERY (MD)
Entity Type:Individual
Prefix:DR
First Name:CLEMENT
Middle Name:EMERY
Last Name:LACOSTE
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 1:105 COUNTRY CLUB PL
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550
Mailing Address - Country:US
Mailing Address - Phone:508-764-6026
Mailing Address - Fax:508-764-7866
Practice Address - Street 1:10 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CHARLTON
Practice Address - State:MA
Practice Address - Zip Code:01507-1590
Practice Address - Country:US
Practice Address - Phone:508-248-6780
Practice Address - Fax:508-248-8134
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA26014208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2087863Medicaid
MAE46026Medicare ID - Type Unspecified
A55108Medicare UPIN