Healthcare Provider Details

I. General information

NPI: 1174554646
Provider Name (Legal Business Name): VERNON HENRY LACKMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 03/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17909 SOLEDAD CANYON RD
CANYON COUNTRY CA
91387-3210
US

IV. Provider business mailing address

PO BOX 9602
MISSION HILLS CA
91346-9602
US

V. Phone/Fax

Practice location:
  • Phone: 661-250-5244
  • Fax: 661-251-7308
Mailing address:
  • Phone: 818-837-5692
  • Fax: 818-792-4793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG67735
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: