Provider Demographics
NPI:1851854830
Name:LACKEY, WALTER BURKE (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:BURKE
Last Name:LACKEY
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 1:2000 E GREENVILLE ST STE 3700
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-1725
Mailing Address - Country:US
Mailing Address - Phone:864-512-1916
Mailing Address - Fax:
Practice Address - Street 1:2000 E GREENVILLE ST STE 3700
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-1725
Practice Address - Country:US
Practice Address - Phone:864-512-1916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC82600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine