Healthcare Provider Details

I. General information

NPI: 1831168673
Provider Name (Legal Business Name): MARIANA E LUCERO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 06/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2132 N KANSAS AVE STE B
LIBERAL KS
67901-2099
US

IV. Provider business mailing address

2132 N KANSAS AVE STE B
LIBERAL KS
67901-2099
US

V. Phone/Fax

Practice location:
  • Phone: 620-624-7400
  • Fax: 620-624-7444
Mailing address:
  • Phone: 620-624-7400
  • Fax: 620-624-7444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0428884
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: