Healthcare Provider Details

I. General information

NPI: 1174632715
Provider Name (Legal Business Name): WALTER WAYNE LUCAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5270 BUDAPEST PL HEALTH UNIT
DULLES VA
20189-5270
US

IV. Provider business mailing address

5270 BUDAPEST PL HEALTH UNIT
DULLES VA
20189-5270
US

V. Phone/Fax

Practice location:
  • Phone: 361-475-4092
  • Fax: 361-311-1802
Mailing address:
  • Phone: 361-475-4092
  • Fax: 361-311-1802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00018340
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: