Provider Demographics
NPI:1679529382
Name:LACKEY, TIMOTHY C (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:C
Last Name:LACKEY
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 1:3555 SUNSET OFFICE DR
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127-1015
Mailing Address - Country:US
Mailing Address - Phone:314-822-5914
Mailing Address - Fax:
Practice Address - Street 1:3555 SUNSET OFFICE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1015
Practice Address - Country:US
Practice Address - Phone:314-966-0252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO103240208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209684513Medicaid
MO209684513Medicaid