Provider Demographics
NPI:1578645305
Name:LACEY, JOHN P JR
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:LACEY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 PLEASANT VALLEY RD
Mailing Address - Street 2:WEST BEND CLINIC-UROLOGY
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-9274
Mailing Address - Country:US
Mailing Address - Phone:262-836-7300
Mailing Address - Fax:262-836-7300
Practice Address - Street 1:3200 PLEASANT VALLEY RD
Practice Address - Street 2:WEST BEND CLINIC-UROLOGY
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-9274
Practice Address - Country:US
Practice Address - Phone:262-836-7300
Practice Address - Fax:262-836-7300
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31345208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1578645305Medicaid
7708OtherINTERNAL ID-MOTOR VEHICLE ID
7708OtherINTERNAL ID-MOTOR VEHICLE ID
WI1578645305Medicaid
WI68086 1041Medicare PIN