Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | DC28121 | CA |
NPI | 1578648135 |
---|---|
Provider Name | Dr. Mark Anthony Lucas |
First Address | San Jose, CA 95126-3824 |
Second Address | San Jose, CA 95125-3006 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/10/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
DC0281210 | CALIFORNIA PROVIDER I.D. (01) | CA |