Provider Demographics
NPI:1952410763
Name:LACAVERA, RICHARD A (DO)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:LACAVERA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20430
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29413-0430
Mailing Address - Country:US
Mailing Address - Phone:843-723-6166
Mailing Address - Fax:843-534-2980
Practice Address - Street 1:7B PITT ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401
Practice Address - Country:US
Practice Address - Phone:843-723-6166
Practice Address - Fax:843-534-2980
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0509207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC005096Medicaid
080145984OtherRAILROAD MEDICARE
SCC536270281Medicare ID - Type Unspecified
C53627Medicare UPIN