Provider Demographics
NPI:1639668742
Name:DAVID M LUCERO MD INC.
Entity type:Organization
Organization Name:DAVID M LUCERO MD INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:LUCERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-855-8882
Mailing Address - Street 1:1219 LARCHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-6407
Mailing Address - Country:US
Mailing Address - Phone:760-855-8882
Mailing Address - Fax:760-659-6533
Practice Address - Street 1:1219 LARCHWOOD DR
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-6407
Practice Address - Country:US
Practice Address - Phone:760-855-8882
Practice Address - Fax:760-659-6533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG74961261QE0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9943731Medicaid