1598062655 NPI number — ANDREW EDWARD LUCKEY III, M.D., INC.

Table of content: (NPI 1598062655)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598062655 NPI number — ANDREW EDWARD LUCKEY III, M.D., INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANDREW EDWARD LUCKEY III, M.D., INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1598062655
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1301 N FAIRFAX AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST HOLLYWOOD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90046-4712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-876-8548
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2650 JONES WAY
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
SIMI VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93065-1203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-577-7977
Provider Business Practice Location Address Fax Number:
805-577-0745
Provider Enumeration Date:
02/24/2011

Additional Information

Authorized Official

Authorized Official Last Name:
LUCKEY
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
805-577-7977

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  A69654 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: A69654 . This is a "STATE MEDICAL LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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