1457309197 NPI number — DAVID W LUCKE MD

Table of content: DAVID W LUCKE MD (NPI 1457309197)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457309197 NPI number — DAVID W LUCKE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUCKE
Provider First Name:
DAVID
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457309197
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/28/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 328
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX CITY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51102-0328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-279-5830
Provider Business Mailing Address Fax Number:
712-279-5883

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
624 JONES ST
Provider Second Line Business Practice Location Address:
STE 5400
Provider Business Practice Location Address City Name:
SIOUX CITY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51105-1924
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-279-2510
Provider Business Practice Location Address Fax Number:
712-279-2519
Provider Enumeration Date:
05/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  20050 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 36902 . This is a "WELLMARK BCBS IA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 100251443-00 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3141721 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7711450 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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