Provider Demographics
NPI:1356347892
Name:LACKAMP, ROBERT JON (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JON
Last Name:LACKAMP
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 1:5501 S MCCOLL RD
Mailing Address - Street 2:STE 500
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-5503
Mailing Address - Country:US
Mailing Address - Phone:952-595-1301
Mailing Address - Fax:612-294-4903
Practice Address - Street 1:5501 S MCCOLL RD
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-5503
Practice Address - Country:US
Practice Address - Phone:956-661-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR67922085R0202X
KS04160552085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOC51529Medicare UPIN
KS100158570EMedicaid
MOP00170928OtherMEDICARE RAILROAD
MOP00377091OtherMEDICARE RAILROAD
AR161134001Medicaid
TX8F3852Medicare PIN
MO902994868Medicare PIN
KSP00612741OtherRR MEDICARE
OK243531204Medicare PIN
OKP00343246OtherMEDICARE RAILROAD
KS107239OtherBLUE CROSS AND BLUE SHIELD
MO200918050Medicaid
KS110357001Medicare PIN
KSR824187Medicare PIN
OK200063590AMedicaid
KS100158570CMedicaid