Provider Demographics
NPI:1841033917
Name:LACKEY, MADISON (MD)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
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:TTUHSC DEPARTMENT OF NEUROLOGY 3601 STREET - STOP 8321
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79430-0001
Mailing Address - Country:US
Mailing Address - Phone:989-860-3697
Mailing Address - Fax:
Practice Address - Street 1:TTUHSC DEPARTMENT OF NEUROLOGY 3601 STREET - STOP 8321
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79430-0001
Practice Address - Country:US
Practice Address - Phone:989-860-3697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10090140390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program