Provider Demographics
NPI:1740570175
Name:LUCERO, STEPHANIE V (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:V
Last Name:LUCERO
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 1:1713 NM 502
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87506-8931
Mailing Address - Country:US
Mailing Address - Phone:505-557-4551
Mailing Address - Fax:505-557-4552
Practice Address - Street 1:1713 NM 502
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87506-8931
Practice Address - Country:US
Practice Address - Phone:505-557-4551
Practice Address - Fax:505-557-4552
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-19
Last Update Date:2019-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2013-0783207Q00000X, 261QU0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program