MEDICARE: THELMA E WILEY-LUCAS 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	207RG0100X	Gastroenterology Physician	058487	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00384988	OTHER	GA	RAIL ROAD MEDICARE

Other Identifiers

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

General Provider Information

NPI Number	:	1366478653
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THELMA E WILEY-LUCAS M.D.

Provider Business Mailing Address
First Line	:	157 CLINIC AVE STE 201
Second Line	:
City	:	CARROLLTON
State	:	GA
Zip	:	30117-4454
Country	:	US
Telephone Number	:	770-214-2800
Fax Number	:	770-214-2803

Provider Business Practice Location Address
First Line	:	157 CLINIC AVE STE 201
Second Line	:
City	:	CARROLLTON
State	:	GA
Zip	:	30117-4454
Country	:	US
Telephone Number	:	770-214-2800
Fax Number	:	770-214-2803

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

Provider Enumeration Date	:	06/25/2006
Last Update Date	:	06/10/2025

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Directions to “ THELMA E WILEY-LUCAS M.D.” Practice Location

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