Basic Information
| Provider Information | |||||||||
| NPI: | 1134177215 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LACY | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | DANFORTH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LACY | ||||||||
| OtherFirstName: | MARK | ||||||||
| OtherMiddleName: | D. | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 5865 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794085865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432898 | ||||||||
| FaxNumber: | 8067432787 | ||||||||
| Practice Location | |||||||||
| Address1: | DEPT INTERNAL MEDICINE 1 UNIVERSITY NM MSC 10-5550 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052721670 | ||||||||
| FaxNumber: | 5052724435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 04/20/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | MD2020-0241 | NM | N | Allopathic & Osteopathic Physicians | Hospitalist | 207RI0200X | MD2020-0241 | NM | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207R00000X | 45341 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | 45341 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RI0200X | 15404 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RI0200X | 01598 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 208000000X | MD2020-0241 | NM | N | Allopathic & Osteopathic Physicians | Pediatrics | 208M00000X | Q8279 | TX | N | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.