Healthcare Provider Details

I. General information

NPI: 1740284389
Provider Name (Legal Business Name): VAN L LACKEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 06/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1227 N STATE ST STE 101
JACKSON MS
39202-2002
US

IV. Provider business mailing address

1227 N STATE ST STE 101
JACKSON MS
39202-2002
US

V. Phone/Fax

Practice location:
  • Phone: 601-355-2485
  • Fax: 601-353-1463
Mailing address:
  • Phone: 601-355-2485
  • Fax: 601-353-1463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number06430
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number06430
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: