Healthcare Provider Details

I. General information

NPI: 1366417990
Provider Name (Legal Business Name): KENNETH WILSON LUCAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 04/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2205 N PARHAM RD
RICHMOND VA
23229-3161
US

IV. Provider business mailing address

5000 COX RD
GLEN ALLEN VA
23060-9263
US

V. Phone/Fax

Practice location:
  • Phone: 804-270-2150
  • Fax:
Mailing address:
  • Phone: 804-968-5700
  • Fax: 804-217-7991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101027078
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: