Provider Demographics
NPI:1912189697
Name:ERNEST A. LUCERO, MD PC
Entity Type:Organization
Organization Name:ERNEST A. LUCERO, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:LUCERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-267-2086
Mailing Address - Street 1:6641 KANIKSU ST STE B
Mailing Address - Street 2:PO BOX 898
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-7532
Mailing Address - Country:US
Mailing Address - Phone:208-267-2086
Mailing Address - Fax:208-267-4013
Practice Address - Street 1:6641 KANIKSU ST STE B
Practice Address - Street 2:
Practice Address - City:BONNERS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83805-7532
Practice Address - Country:US
Practice Address - Phone:208-267-2086
Practice Address - Fax:208-267-4013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5577208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DA558OtherBLUE CROSS OF IDAHO
ID000010003687OtherBLUE SHIELD OF IDAHO
ID000010003687OtherBLUE SHIELD OF IDAHO