Provider Demographics
NPI:1578571469
Name:LACKEY, ROY S (MD)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:S
Last Name:LACKEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 FORT WASHINGTON AVE
Mailing Address - Street 2:SUITE 421
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3729
Mailing Address - Country:US
Mailing Address - Phone:212-305-2001
Mailing Address - Fax:212-305-0713
Practice Address - Street 1:161 FORT WASHINGTON AVE
Practice Address - Street 2:SUITE 421
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3729
Practice Address - Country:US
Practice Address - Phone:212-305-2001
Practice Address - Fax:212-305-0713
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200011207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY763101Medicare ID - Type Unspecified
G29876Medicare UPIN