Provider Demographics
NPI:1750480554
Name:ELIJOVICH, LUCAS (MD)
Entity Type:Individual
Prefix:DR
First Name:LUCAS
Middle Name:
Last Name:ELIJOVICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6325 HUMPHREYS BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2300
Mailing Address - Country:US
Mailing Address - Phone:901-522-7700
Mailing Address - Fax:
Practice Address - Street 1:6325 HUMPHREYS BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2300
Practice Address - Country:US
Practice Address - Phone:901-522-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA955212084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1518721Medicaid
TN1518721Medicaid