Individual
JOHN LACKEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
500 S 11TH AVE, POCATELLO, ID 83201-4835
(208) 232-3103
(208) 232-0756
Mailing address
700 CANYON DR, POCATELLO, ID 83204-4840
(208) 234-1921
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
M3873
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
002487500
—
ID
Enumeration date
06/15/2006
Last updated
07/08/2007
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