Provider Demographics
NPI:1023110665
Name:LUCAS, KENNETH J (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
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 1:405 N CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2730
Mailing Address - Country:US
Mailing Address - Phone:386-257-1626
Mailing Address - Fax:386-254-7507
Practice Address - Street 1:405 N CLYDE MORRIS BLVD
Practice Address - Street 2:405 N CLYDE MORRIS BLVD
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2730
Practice Address - Country:US
Practice Address - Phone:386-257-1626
Practice Address - Fax:386-254-7507
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME22441207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD57642Medicare UPIN
FL64328UMedicare PIN