Provider Demographics
NPI:1639490550
Name:KEITH, LUCAS AG (MD)
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:AG
Last Name:KEITH
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 1:3669 COUNTRYSIDE LN
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:NY
Mailing Address - Zip Code:14505-9781
Mailing Address - Country:US
Mailing Address - Phone:315-926-7733
Mailing Address - Fax:315-926-0731
Practice Address - Street 1:3669 COUNTRYSIDE LN
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:NY
Practice Address - Zip Code:14505
Practice Address - Country:US
Practice Address - Phone:315-926-7733
Practice Address - Fax:315-926-0731
Is Sole Proprietor?:No
Enumeration Date:2010-06-15
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN54151207R00000X
NY292399207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MN110014932Medicare PIN