Provider Demographics
NPI:1710259692
Name:STEPHEN LUCERO, MD, PC
Entity Type:Organization
Organization Name:STEPHEN LUCERO, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:LUCERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-989-8325
Mailing Address - Street 1:1650 HOSPITAL DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4769
Mailing Address - Country:US
Mailing Address - Phone:505-989-8325
Mailing Address - Fax:505-982-7665
Practice Address - Street 1:1650 HOSPITAL DR
Practice Address - Street 2:SUITE 300
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4769
Practice Address - Country:US
Practice Address - Phone:505-989-8325
Practice Address - Fax:505-982-7665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-07
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM86 273208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM 101791OtherGROUP PTAN
NMNM 101792OtherINDIVIDUAL PTAN
NM37481Medicaid
NM37481Medicaid
C97937Medicare UPIN