Provider Demographics
NPI:1447336094
Name:LACKORE, RAYMOND C (MD)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:C
Last Name:LACKORE
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 1:1101 FIRST COLONIAL RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-2409
Mailing Address - Country:US
Mailing Address - Phone:757-481-3366
Mailing Address - Fax:
Practice Address - Street 1:1101 FIRST COLONIAL RD STE 100
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2409
Practice Address - Country:US
Practice Address - Phone:757-481-3366
Practice Address - Fax:757-496-3889
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101036490207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1447336094OtherNPI
VA006230610Medicaid