Provider Demographics
NPI:1972543452
Name:LUCCAS, BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:LUCCAS
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 1:3805B SPRING ST
Mailing Address - Street 2:SUITE 130
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-1641
Mailing Address - Country:US
Mailing Address - Phone:262-631-8750
Mailing Address - Fax:262-631-8754
Practice Address - Street 1:3805B SPRING ST
Practice Address - Street 2:SUITE 130
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405-1641
Practice Address - Country:US
Practice Address - Phone:262-631-8750
Practice Address - Fax:262-631-8754
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29473207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31555600Medicaid
WI000152130Medicare PIN
WI31555600Medicaid