Provider Demographics
NPI:1649304395
Name:CARLOS E LUCERO
Entity type:Organization
Organization Name:CARLOS E LUCERO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:ESTANISLAO
Authorized Official - Last Name:LUCERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-255-7456
Mailing Address - Street 1:403 CARRIAGE DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801
Mailing Address - Country:US
Mailing Address - Phone:304-255-7456
Mailing Address - Fax:304-255-5899
Practice Address - Street 1:403 CARRIAGE DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2805
Practice Address - Country:US
Practice Address - Phone:304-255-7456
Practice Address - Fax:304-255-5899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV103552080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0112021000Medicaid
WV3810002253OtherMEDICAID GROUP
WV3810002253Medicaid