Provider Demographics
NPI:1821064288
Name:LACEY, MARTIN S (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:S
Last Name:LACEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:8100 34TH AVE S
Mailing Address - Street 2:MAIL STOP 21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:952-883-5463
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:640 JACKSON ST
Practice Address - Street 2:MC 11503B
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2502
Practice Address - Country:US
Practice Address - Phone:651-254-3792
Practice Address - Fax:651-254-8208
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2012-10-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN443532086S0122X
WI457622086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN322800200Medicaid
240000255Medicare ID - Type Unspecified
MN322800200Medicaid