Provider Demographics
NPI:1952511875
Name:LACY, CLIFTON R (MD)
Entity Type:Individual
Prefix:DR
First Name:CLIFTON
Middle Name:R
Last Name:LACY
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:PO BOX 1458
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08904-1458
Mailing Address - Country:US
Mailing Address - Phone:732-821-6810
Mailing Address - Fax:
Practice Address - Street 1:125 PATERSON ST
Practice Address - Street 2:SUITE 5200
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1962
Practice Address - Country:US
Practice Address - Phone:732-235-8966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04066100207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1912003Medicaid
NJ1912003Medicaid
NJ197678Medicare ID - Type Unspecified