Healthcare Provider Details

I. General information

NPI: 1073590295
Provider Name (Legal Business Name): CHRISTOPHER I LACY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 MONTAUK AVE
NEW LONDON CT
06320-4700
US

IV. Provider business mailing address

PO BOX 410197
BOSTON MA
02241-1097
US

V. Phone/Fax

Practice location:
  • Phone: 860-442-0711
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number045865
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: