Provider Demographics
NPI:1578648135
Name:LUCAS, MARK ANTHONY (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANTHONY
Last Name:LUCAS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 PAULA ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-3824
Mailing Address - Country:US
Mailing Address - Phone:408-297-7640
Mailing Address - Fax:
Practice Address - Street 1:1261 LINCOLN AVE
Practice Address - Street 2:112
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-3006
Practice Address - Country:US
Practice Address - Phone:408-294-4074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28121111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0281210OtherCALIFORNIA PROVIDER I.D.