Provider Demographics
NPI:1689748261
Name:LACKEY, SUSAN HAMMAN (DO)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:HAMMAN
Last Name:LACKEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7946 MULBERRY RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44026-1338
Mailing Address - Country:US
Mailing Address - Phone:440-729-3144
Mailing Address - Fax:
Practice Address - Street 1:7946 MULBERRY RD
Practice Address - Street 2:
Practice Address - City:CHESTERLAND
Practice Address - State:OH
Practice Address - Zip Code:44026-1338
Practice Address - Country:US
Practice Address - Phone:440-729-3144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.002638207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0500783Medicaid
OHA76311Medicare UPIN
OHLA0437502Medicare ID - Type Unspecified