Healthcare Provider Details

I. General information

NPI: 1356330518
Provider Name (Legal Business Name): CHARLES S LUCAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 HOWELL BRANCH RD SUITE B2
WINTER PARK FL
32789-1109
US

IV. Provider business mailing address

1555 HOWELL BRANCH RD SUITE B2
WINTER PARK FL
32789-1109
US

V. Phone/Fax

Practice location:
  • Phone: 407-644-6465
  • Fax: 407-647-4251
Mailing address:
  • Phone: 407-644-6465
  • Fax: 407-647-4251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME14577
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: