Provider Demographics
NPI:1588681274
Name:GWYNN, LUCAS KIDD (MD)
Entity Type:Individual
Prefix:DR
First Name:LUCAS
Middle Name:KIDD
Last Name:GWYNN
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 1:6408 SEVEN CORNERS PL
Mailing Address - Street 2:SUITE J
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22044-2011
Mailing Address - Country:US
Mailing Address - Phone:703-531-1030
Mailing Address - Fax:703-531-1031
Practice Address - Street 1:6408 SEVEN CORNERS PL
Practice Address - Street 2:SUITE J
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22044-2034
Practice Address - Country:US
Practice Address - Phone:703-531-1030
Practice Address - Fax:703-531-1031
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101223967207N00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatology
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA146092OtherANTHEM BCBS
VA279883OtherAMERIGROUP
VA491771Medicare ID - Type Unspecified
VAI09438Medicare UPIN