Healthcare Provider Details

I. General information

NPI: 1275780934
Provider Name (Legal Business Name): TIMOTHY JEROME LACY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2008
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10630 LITTLE PATUXENT PKWY STE 209
COLUMBIA MD
21044
US

IV. Provider business mailing address

2916 PARKER AVE
SILVER SPRING MD
20902-2660
US

V. Phone/Fax

Practice location:
  • Phone: 410-740-8067
  • Fax:
Mailing address:
  • Phone: 301-512-9726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD0047144
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: