Provider Demographics
NPI:1740284389
Name:LACKEY, VAN L (MD)
Entity type:Individual
Prefix:
First Name:VAN
Middle Name:L
Last Name:LACKEY
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 1:1227 N STATE ST
Mailing Address - Street 2:STE 101
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2002
Mailing Address - Country:US
Mailing Address - Phone:601-355-2485
Mailing Address - Fax:601-353-1463
Practice Address - Street 1:1227 N STATE ST
Practice Address - Street 2:STE 101
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2002
Practice Address - Country:US
Practice Address - Phone:601-355-2485
Practice Address - Fax:601-353-1463
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06430207RH0003X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
4285654OtherAETNA HEALTHCARE
MS00115429Medicaid
LA1541575Medicaid
LA1541575Medicaid