Provider Demographics
NPI:1174554646
Name:LACKMAN, VERNON HENRY (MD)
Entity type:Individual
Prefix:
First Name:VERNON
Middle Name:HENRY
Last Name:LACKMAN
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:PO BOX 9602
Mailing Address - Street 2:
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91346-9602
Mailing Address - Country:US
Mailing Address - Phone:818-837-5692
Mailing Address - Fax:818-792-4793
Practice Address - Street 1:17909 SOLEDAD CANYON RD
Practice Address - Street 2:
Practice Address - City:CANYON COUNTRY
Practice Address - State:CA
Practice Address - Zip Code:91387-3210
Practice Address - Country:US
Practice Address - Phone:661-250-5244
Practice Address - Fax:661-251-7308
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG67735207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G677350Medicaid
CAWG67735Medicare ID - Type UnspecifiedPPIN
CAWG67735AMedicare PIN
CAE96823Medicare UPIN