Organization
DR JOHN LACKEY INC
Active
Other names
John K. Lackey, D.O.
Organization subpart
No
Provider details
NPI number
Authorized official
JOHN K LACKEY D.O. (OWNER PHYSICIAN)
(304) 872-6433
Entity
Organization
Contact information
Practice address
702 PROFESSIONAL PARK DR, SUITE 102, SUMMERSVILLE, WV 26651-2018
(304) 872-6433
(304) 872-6562
Mailing address
702 PROFESSIONAL PARK DR, SUITE 102, SUMMERSVILLE, WV 26651-2018
(304) 872-6433
(304) 872-6562
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
Primary
736 WV
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0094926001
MEDICAID - SUPPLIER
WV
01
—
0094926002
MEDICAID GROUP
WI
01
—
1205951605
NPI - GROUP
WV
01
—
1329809
UMWA FUNDS
WV
01
—
DG9055
MEDICARE RAILROAD GROUP
WV
Enumeration date
03/21/2007
Last updated
02/21/2011
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