Provider Demographics
NPI:1043277247
Name:LACEY, DAVID LAWRENCE (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:LAWRENCE
Last Name:LACEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13338 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-8740
Mailing Address - Country:US
Mailing Address - Phone:515-254-0336
Mailing Address - Fax:
Practice Address - Street 1:12368 STRATFORD DR
Practice Address - Street 2:SUITE 300
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8162
Practice Address - Country:US
Practice Address - Phone:515-226-9810
Practice Address - Fax:515-226-8408
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA324792085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA3189886Medicaid
IA3189886Medicaid
G70664Medicare UPIN