Healthcare Provider Details

I. General information

NPI: 1548302615
Provider Name (Legal Business Name): JEFFREY N LACKEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 10/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WALTER REED NATIONAL MILITARY CTR 8901 WISCONSIN AVE
BETHESDA MD
20889-0001
US

IV. Provider business mailing address

WALTER REED NATIONAL MILITARY CTR 8901 WISCONSIN AVE
BETHESDA MD
20889-0001
US

V. Phone/Fax

Practice location:
  • Phone: 301-295-4551
  • Fax:
Mailing address:
  • Phone: 301-295-4551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number308166
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number0101242335
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: