Provider Demographics
NPI:1912016742
Name:LUCAS, JERRY ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:ALLEN
Last Name:LUCAS
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 1:5204 PAULSEN ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-4704
Mailing Address - Country:US
Mailing Address - Phone:912-819-4491
Mailing Address - Fax:912-819-4173
Practice Address - Street 1:5204 PAULSEN ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4704
Practice Address - Country:US
Practice Address - Phone:000-000-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101055788207V00000X
GA90992207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA160043283QOtherRAILROAD MEDICARE ID#
VA541467765OtherTAX ID#
GA90992OtherSTATE LICENSE
VA006210082Medicaid
VA952279OtherAETNA ID#
VA271664OtherANTHEM BC/BS ID#
VA5414523OtherAETNA
VA45748OtherOPTIMA SENTARA ID#
VA20507OtherVIRGINIA PREMIER ID #
VA006210082Medicaid
VA160001486Medicare PIN