Provider Demographics
NPI:1356391676
Name:LUCENA, BERNARDO (MD)
Entity type:Individual
Prefix:
First Name:BERNARDO
Middle Name:
Last Name:LUCENA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1040 SIERRA DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-7241
Mailing Address - Country:US
Mailing Address - Phone:317-528-4252
Mailing Address - Fax:317-865-8318
Practice Address - Street 1:12800 MISSISSIPPI ST
Practice Address - Street 2:B201
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-6900
Practice Address - Country:US
Practice Address - Phone:219-663-7000
Practice Address - Fax:219-663-8621
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01039302A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000721917OtherANTHEM TRADITIONAL
IN100354630Medicaid
INM400049821Medicare PIN
IN202790IMedicare PIN
IN100354630Medicaid