Provider Demographics
NPI:1508964487
Name:LACEY, JOHN W (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:W
Last Name:LACEY
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:PO BOX 440248
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37244-0248
Mailing Address - Country:US
Mailing Address - Phone:865-670-6199
Mailing Address - Fax:865-670-6198
Practice Address - Street 1:1940 ALCOA HWY
Practice Address - Street 2:E180
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-2244
Practice Address - Country:US
Practice Address - Phone:865-305-6810
Practice Address - Fax:865-305-6803
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000008513207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3163298Medicaid
TN103I113953Medicare PIN
TN3163298Medicaid