Provider Demographics
NPI:1225386071
Name:H.PEYTON LUCKETT, M.D., PA
Entity type:Organization
Organization Name:H.PEYTON LUCKETT, M.D., PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:P
Authorized Official - Last Name:LUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-595-2211
Mailing Address - Street 1:700 OLYMPIC PLAZA CIR STE 503
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1952
Mailing Address - Country:US
Mailing Address - Phone:903-595-2211
Mailing Address - Fax:903-595-1397
Practice Address - Street 1:700 OLYMPIC PLAZA CIR STE 503
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1952
Practice Address - Country:US
Practice Address - Phone:903-595-2211
Practice Address - Fax:903-595-1397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-28
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6130261QM2500X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care