Provider Demographics
NPI:1396772224
Name:W.D.LUCKY, M.D., INC
Entity type:Organization
Organization Name:W.D.LUCKY, M.D., INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:LUCKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-238-3990
Mailing Address - Street 1:13520 SW 152ND ST
Mailing Address - Street 2:#771834
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-0031
Mailing Address - Country:US
Mailing Address - Phone:305-238-3990
Mailing Address - Fax:
Practice Address - Street 1:13520 SW 152ND ST
Practice Address - Street 2:#771834
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-0031
Practice Address - Country:US
Practice Address - Phone:305-238-3990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0029049174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL038136500Medicaid
FL95193YOtherFL MEDICARE INDIVIDUAL PTAN
FLK5918Medicare ID - Type Unspecified
FL038136500Medicaid
FLK5918CMedicare PIN