MEDICARE: DR. JERRY ALLEN LUCAS 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	207V00000X	Obstetrics & Gynecology Physician	0101055788	VA
2	207VX0000X	Obstetrics Physician	90992	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	160043283Q	OTHER	VA	RAILROAD MEDICARE ID#

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	45748	OTHER	VA	OPTIMA SENTARA ID#
3	541467765	OTHER	VA	TAX ID#
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	20507	OTHER	VA	VIRGINIA PREMIER ID #
6	952279	OTHER	VA	AETNA ID#
7	90992	OTHER	GA	STATE LICENSE
8	5414523	OTHER	VA	AETNA
9	271664	OTHER	VA	ANTHEM BC/BS ID#

General Provider Information

NPI Number	:	1912016742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRY ALLEN LUCAS MD

Provider Business Mailing Address
First Line	:	836 E 65TH ST STE 22
Second Line	:
City	:	SAVANNAH
State	:	GA
Zip	:	31405-4493
Country	:	US
Telephone Number	:	912-819-7171
Fax Number	:	912-691-9287

Provider Business Practice Location Address
First Line	:	5354 REYNOLDS ST STE 315
Second Line	:
City	:	SAVANNAH
State	:	GA
Zip	:	31405-6010
Country	:	US
Telephone Number	:	912-354-2634
Fax Number	:

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

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	06/05/2024

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Directions to “ DR. JERRY ALLEN LUCAS MD” Practice Location

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