Provider Demographics
NPI:1013442177
Name:POLICASTRO, LUCAS J (MD)
Entity Type:Individual
Prefix:DR
First Name:LUCAS
Middle Name:J
Last Name:POLICASTRO
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 1:302 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326-8801
Mailing Address - Country:US
Mailing Address - Phone:201-497-0053
Mailing Address - Fax:201-831-9100
Practice Address - Street 1:302 W 5TH ST
Practice Address - Street 2:
Practice Address - City:RINCON
Practice Address - State:GA
Practice Address - Zip Code:31326-8801
Practice Address - Country:US
Practice Address - Phone:201-497-0053
Practice Address - Fax:201-831-9100
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-26
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA84180207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine