Provider Demographics
NPI:1639173115
Name:LUCERO, MARIO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:LUCERO
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:ROUTE 16, MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WAR
Mailing Address - State:WV
Mailing Address - Zip Code:24892
Mailing Address - Country:US
Mailing Address - Phone:304-425-1768
Mailing Address - Fax:304-425-3912
Practice Address - Street 1:ROUTE 16, MAIN STREET
Practice Address - Street 2:
Practice Address - City:WAR
Practice Address - State:WV
Practice Address - Zip Code:24892
Practice Address - Country:US
Practice Address - Phone:304-425-1768
Practice Address - Fax:304-425-3912
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2008-03-13
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-04-04
Provider Licenses
StateLicense IDTaxonomies
WVWV 13411171W00000X
WVWV13411170100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical Genetics
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0049852000Medicaid
WV0049852000Medicaid
SP01521Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER