Provider Demographics
NPI:1952410797
Name:PICKRELL, LANCE A (MD)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:A
Last Name:PICKRELL
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 1:221 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-4214
Mailing Address - Country:US
Mailing Address - Phone:812-242-3700
Mailing Address - Fax:812-234-3565
Practice Address - Street 1:422 POPLAR ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-4209
Practice Address - Country:US
Practice Address - Phone:812-242-3700
Practice Address - Fax:812-234-3565
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030052A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0182814OtherUS DEPT OF LABOR
351904269190OtherCARESOURCE MEDICAID
I017569C002OtherUNISYS CHAMPUS SECONDARY
000000089613OtherANTHEM
IN100251650DOtherMOLINA HEALTHCARE MCAID
INP00844288OtherRAILROAD MEDICARE
N286520OtherHARMONY HEALTH PLAN IND
IN100251650Medicaid
180018771OtherRAILROAD MCARE PALAMETTO
01419OtherCIGNA
4062089OtherAETNA
118392OtherHEALTHLINK
IN859940CMedicare PIN
000000089613OtherANTHEM
I017569C002OtherUNISYS CHAMPUS SECONDARY
IN859910C3Medicare PIN
351904269190OtherCARESOURCE MEDICAID