Provider Demographics
NPI:1528016532
Name:LACKEY, CHARLES W (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:W
Last Name:LACKEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 138
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47701-0138
Mailing Address - Country:US
Mailing Address - Phone:812-471-1591
Mailing Address - Fax:812-471-6650
Practice Address - Street 1:100 ST MARYS EPWORTH XING
Practice Address - Street 2:STE. A500
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-9698
Practice Address - Country:US
Practice Address - Phone:812-471-1591
Practice Address - Fax:812-471-6650
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
IN99025381A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
H96174Medicare UPIN