Healthcare Provider Details

I. General information

NPI: 1376561985
Provider Name (Legal Business Name): THOMAS A. LACY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 12/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11715 ORPINGTON STREET, SUITE A TLC PEDIATRICS AND ADOLESCENT MEDICINE IN ASSOC WITH NE
ORLANDO FL
32817-4600
US

IV. Provider business mailing address

P.O. BOX 191 PROVIDER ENROLLMENT DEPARTMENT
ROCKLAND DE
19732-0191
US

V. Phone/Fax

Practice location:
  • Phone: 407-380-9115
  • Fax: 407-380-9189
Mailing address:
  • Phone: 302-651-4488
  • Fax: 302-651-4945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME58227
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME58227
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: