Provider Demographics
NPI:1063418572
Name:LUCKASEN, GARY J (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:J
Last Name:LUCKASEN
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 1:2121 E HARMONY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3400
Mailing Address - Country:US
Mailing Address - Phone:970-221-1000
Mailing Address - Fax:970-297-6860
Practice Address - Street 1:2121 E HARMONY RD
Practice Address - Street 2:UNIT 100
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3401
Practice Address - Country:US
Practice Address - Phone:970-221-1000
Practice Address - Fax:970-297-6860
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20789207RC0000X
NE19652207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEP00970356OtherMEDICARE RAILROAD
WY103400600Medicaid
CO01207893Medicaid
COP00910572OtherMEDICARE RAILROAD
NEP00970356OtherMEDICARE RAILROAD
WY103400600Medicaid
NENA1625013Medicare PIN
D23832Medicare UPIN