Provider Demographics
NPI:1629615588
Name:KELLY LUCAS DPM PC
Entity Type:Organization
Organization Name:KELLY LUCAS DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:M
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:516-352-4454
Mailing Address - Street 1:73 E SHORE RD
Mailing Address - Street 2:
Mailing Address - City:HALESITE
Mailing Address - State:NY
Mailing Address - Zip Code:11743-1127
Mailing Address - Country:US
Mailing Address - Phone:516-352-4454
Mailing Address - Fax:
Practice Address - Street 1:925 HEMPSTEAD TPKE STE 110
Practice Address - Street 2:
Practice Address - City:FRANKLIN SQUARE
Practice Address - State:NY
Practice Address - Zip Code:11010-3636
Practice Address - Country:US
Practice Address - Phone:516-352-4454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-10
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty