Healthcare Provider Details

I. General information

NPI: 1508291436
Provider Name (Legal Business Name): LUCAS BINGHAM M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2013
Last Update Date: 10/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 CORPORATE DR STE 100
LADERA RANCH CA
92694
US

IV. Provider business mailing address

600 CORPORATE DR STE 100
LADERA RANCH CA
92694-2107
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 TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA104512
License Number StateCA

VIII. Authorized Official

Name: LUCAS GARDNER BINGHAM
Title or Position: DERMATOLOGIST
Credential: M.D.
Phone: 801-830-7222