Provider Demographics
NPI:1720005374
Name:LACKEY, VICTORIA DONOVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:DONOVAN
Last Name:LACKEY
Suffix:
Gender:F
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:MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-716-4209
Mailing Address - Fax:336-716-9916
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-1198
Practice Address - Country:US
Practice Address - Phone:336-716-4209
Practice Address - Fax:336-716-9916
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9600226207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1720005374Medicaid
SCN00226Medicaid
NC8950529Medicaid
NCF68310Medicare UPIN
NC1720005374Medicaid
NC8950529Medicaid
NCNCO868AMedicare PIN
NC2223504KMedicare PIN