Provider Demographics
NPI:1386712966
Name:JOHNSON, LUCKETT (MD)
Entity type:Individual
Prefix:DR
First Name:LUCKETT
Middle Name:
Last Name:JOHNSON
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:PO BOX 301078
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77230-1078
Mailing Address - Country:US
Mailing Address - Phone:713-669-9199
Mailing Address - Fax:713-669-9254
Practice Address - Street 1:2600 SOUTH LOOP WEST SUITE 100
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054
Practice Address - Country:US
Practice Address - Phone:713-669-9199
Practice Address - Fax:713-669-9254
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4123207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MK13Medicare ID - Type Unspecified
C17489Medicare UPIN