Healthcare Provider Details

I. General information

NPI: 1194319277
Provider Name (Legal Business Name): LUCAS MEEHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2021
Last Update Date: 07/01/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

366 MDG/CSS 90 HOPE DR. BLDG. 6000
MOUNTAIN HOME AFB ID
83648
US

IV. Provider business mailing address

3551 ROGER BROOKE DR
SAN ANTONIO TX
78234-4504
US

V. Phone/Fax

Practice location:
  • Phone: 208-828-6806
  • Fax:
Mailing address:
  • Phone: 210-916-9100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101276833
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101276833
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: