Provider Demographics
NPI:1134177215
Name:LACY, MARK DANFORTH (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DANFORTH
Last Name:LACY
Suffix:
Gender:
Credentials:MD
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:D
Other - Last Name:LACY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 5865
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79408-5865
Mailing Address - Country:US
Mailing Address - Phone:806-743-2898
Mailing Address - Fax:806-743-2787
Practice Address - Street 1:DEPT INTERNAL MEDICINE 1 UNIVERSITY NM MSC 10-5550
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-272-1670
Practice Address - Fax:505-272-4435
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT143343207RI0200X
TX45341207RI0200X, 207R00000X
AZ15404207RI0200X
NC01598207RI0200X
NMMD2020-0241208000000X, 208M00000X, 207RI0200X
TXQ8279208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZA72799Medicare UPIN