Healthcare Provider Details

I. General information

NPI: 1295700987
Provider Name (Legal Business Name): LUCAS G BINGHAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 10/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 CORPORATE DR STE 100
LADERA RANCH CA
92694-2106
US

IV. Provider business mailing address

600 CORPORATE DR STE 100
LADERA RANCH CA
92694-2106
US

V. Phone/Fax

Practice location:
  • Phone: 949-388-8022
  • Fax: 949-388-8033
Mailing address:
  • Phone: 949-388-8022
  • Fax: 949-388-8033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number47852
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number36857
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA104512
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: