Healthcare Provider Details

I. General information

NPI: 1699270991
Provider Name (Legal Business Name): LUCAS ALFONSO BRACERO MD, MBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 02/15/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 COURT ST STE 100
CHARLESTON WV
25301-1652
US

IV. Provider business mailing address

400 COURT ST STE 100
CHARLESTON WV
25301-1652
US

V. Phone/Fax

Practice location:
  • Phone: 304-347-6120
  • Fax: 304-347-6120
Mailing address:
  • Phone: 304-347-6120
  • Fax: 304-347-6126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number32685
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: