Provider Demographics
NPI:1750507463
Name:JANTAC, LUKAS (MD)
Entity Type:Individual
Prefix:
First Name:LUKAS
Middle Name:
Last Name:JANTAC
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 1:205 PAGE ROAD
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-8798
Mailing Address - Country:US
Mailing Address - Phone:910-295-5511
Mailing Address - Fax:
Practice Address - Street 1:110 FIELDS DR
Practice Address - Street 2:SUITE A
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-5072
Practice Address - Country:US
Practice Address - Phone:919-777-9005
Practice Address - Fax:919-708-1550
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200400884207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC145J1OtherBCBS NC
NCFH2967430OtherFIRSTCAROLINACARE #
NC5906881Medicaid
NC199499OtherMEDCOST PROVIDER NUMBER
NC145J1OtherBCBS NC
NC5906881Medicaid
2067377AMedicare PIN