Provider Demographics
NPI:1659692952
Name:LUCAS, JOHN ALBERT IV (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ALBERT
Last Name:LUCAS
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:2755 S HIGHWAY 14
Practice Address - Street 2:SUITE 1200L
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-4902
Practice Address - Country:US
Practice Address - Phone:864-849-9150
Practice Address - Fax:864-849-9334
Is Sole Proprietor?:No
Enumeration Date:2010-06-21
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC36938207Q00000X, 207QS0010X
SCTL36938207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC3619J577OtherMEDICARE PIN
SCSC36196121OtherMEDICARE PIN
SC369381Medicaid
SCSC36196067OtherMEDICARE PIN
SCSC36196084OtherMEDICARE PIN
SCSC36197628OtherMEDICARE PIN