Provider Demographics
NPI:1780115329
Name:LUCEY, MARK JR
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LUCEY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 SOUTH ST
Mailing Address - Street 2:APT 1
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-3882
Mailing Address - Country:US
Mailing Address - Phone:860-324-1249
Mailing Address - Fax:508-342-1181
Practice Address - Street 1:4190 CITY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-1626
Practice Address - Country:US
Practice Address - Phone:215-871-6690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-24
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAT290070207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine