MEDICARE: DR. LUCAS ANISSIAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician	201054	LA
2	207X00000X	Orthopaedic Surgery Physician	ME111701	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285669390
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LUCAS ANISSIAN M.D.

Provider Business Mailing Address
First Line	:	1665 KINGSLEY AVE
Second Line	:	SUITE 107
City	:	ORANGE PARK
State	:	FL
Zip	:	32073-4490
Country	:	US
Telephone Number	:	904-269-6565
Fax Number	:	904-269-0529

Provider Business Practice Location Address
First Line	:	4689 US HIGHWAY 17
Second Line	:
City	:	FLEMING ISLAND
State	:	FL
Zip	:	32003-4831
Country	:	US
Telephone Number	:	904-269-7007
Fax Number	:	904-269-0529

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	06/27/2013

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