Provider Demographics
NPI:1053392951
Name:LACY, JILL (MD)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:LACY
Suffix:
Gender:F
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 9805
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06536-0805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 HOWARD AVE
Practice Address - Street 2:YALE PHYSICIANS BLDG-2ND FLOOR
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1369
Practice Address - Country:US
Practice Address - Phone:203-737-1600
Practice Address - Fax:203-737-2617
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT022937207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001229376Medicaid
CT110001782Medicare ID - Type Unspecified
D85283Medicare UPIN