Healthcare Provider Details

I. General information

NPI: 1912016742
Provider Name (Legal Business Name): JERRY ALLEN LUCAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5354 REYNOLDS ST STE 315
SAVANNAH GA
31405-6010
US

IV. Provider business mailing address

836 E 65TH ST STE 22
SAVANNAH GA
31405-4493
US

V. Phone/Fax

Practice location:
  • Phone: 912-354-2634
  • Fax:
Mailing address:
  • Phone: 912-819-7171
  • Fax: 912-691-9287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101055788
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number90992
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: