Healthcare Provider Details

I. General information

NPI: 1831181270
Provider Name (Legal Business Name): IRENE DIANE LUCAS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 07/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 N MOUNTAIN BLVD
MOUNTAIN TOP PA
18707-1117
US

IV. Provider business mailing address

62 N MOUNTAIN BLVD
MOUNTAIN TOP PA
18707-1117
US

V. Phone/Fax

Practice location:
  • Phone: 570-474-6562
  • Fax: 570-474-0796
Mailing address:
  • Phone: 570-474-6562
  • Fax: 570-474-0796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD0339709
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: