Provider Demographics
NPI:1831291459
Name:LUCAS, JONATHAN (OD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:LUCAS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 WALLER ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2945
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1805 WALLER ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-2945
Practice Address - Country:US
Practice Address - Phone:740-353-4511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3621152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0492935Medicaid
OH0492935Medicaid
OH0656660001Medicare NSC
OHP00344989Medicare PIN