Provider Demographics
NPI:1023116068
Name:LUCAS, STEPHENIE M (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHENIE
Middle Name:M
Last Name:LUCAS
Suffix:
Gender:F
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 44047
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48244-0047
Mailing Address - Country:US
Mailing Address - Phone:248-584-0240
Mailing Address - Fax:248-584-0241
Practice Address - Street 1:22631 GREATER MACK AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2055
Practice Address - Country:US
Practice Address - Phone:586-771-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISL032256208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2713258Medicaid
MIA74387Medicare UPIN
MION62180Medicare ID - Type Unspecified