Provider Demographics
NPI:1710056304
Name:LUCAS, DAVID W (OD)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:W
Last Name:LUCAS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 N HELMER RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:49037-7931
Mailing Address - Country:US
Mailing Address - Phone:269-963-5640
Mailing Address - Fax:269-963-1666
Practice Address - Street 1:228 N HELMER RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MI
Practice Address - Zip Code:49037-7931
Practice Address - Country:US
Practice Address - Phone:269-963-5640
Practice Address - Fax:269-963-1666
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002338152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI945005485Medicaid
MIT32668Medicare UPIN
MI945005485Medicaid
MI6180720001Medicare NSC