Provider Demographics
NPI:1902883903
Name:LUCERO, MANUEL PAULIN (MD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:PAULIN
Last Name:LUCERO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121A BELLEVUE RD
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021
Mailing Address - Country:US
Mailing Address - Phone:478-272-1190
Mailing Address - Fax:478-274-7628
Practice Address - Street 1:2121A BELLEVUE RD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021
Practice Address - Country:US
Practice Address - Phone:478-272-1190
Practice Address - Fax:478-274-7628
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0290312084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300030912AMedicaid
GA00606284HMedicaid
26BDJBWMedicare ID - Type Unspecified
GA00606284HMedicaid