MEDICARE: DR. JAMES MANNING LACKEY MD

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	207Q00000X	Family Medicine Physician	L5014	TX

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	Y29190	OTHER	TX	UPIN NUMBER
4	L5014	OTHER	TX	TX LICENSE NUMBER
5	8CJ355	OTHER	TX	BLUECROSS BLUESHIELD

General Provider Information

NPI Number	:	1730255050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES MANNING LACKEY MD

Provider Business Mailing Address
First Line	:	1045 CENTRAL PARKWAY NORTH
Second Line	:	SUITE 200
City	:	SAN ANTONIO
State	:	TX
Zip	:	78232-5024
Country	:	US
Telephone Number	:	210-541-4500
Fax Number	:	210-541-4508

Provider Business Practice Location Address
First Line	:	2235 THOUSAND OAKS DR
Second Line	:	SUITE #117
City	:	SAN ANTONIO
State	:	TX
Zip	:	78232-3966
Country	:	US
Telephone Number	:	210-490-1000
Fax Number	:	210-496-3590

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

Provider Enumeration Date	:	11/28/2006
Last Update Date	:	11/01/2012

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Directions to “ DR. JAMES MANNING LACKEY MD” Practice Location

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