Provider Demographics
NPI:1093725079
Name:LUCKIE, JAMES EDWIN JR (DO)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:EDWIN
Last Name:LUCKIE
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1349
Mailing Address - Street 2:
Mailing Address - City:FITZGERALD
Mailing Address - State:GA
Mailing Address - Zip Code:31750-1349
Mailing Address - Country:US
Mailing Address - Phone:229-423-8725
Mailing Address - Fax:229-423-8726
Practice Address - Street 1:182 PERRY HOUSE RD
Practice Address - Street 2:SUITE E
Practice Address - City:FITZGERALD
Practice Address - State:GA
Practice Address - Zip Code:31750-8721
Practice Address - Country:US
Practice Address - Phone:229-423-8725
Practice Address - Fax:229-423-8726
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA19720207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000153821AMedicaid
GA581331734OtherTAX IDENTIFICATION NUMBER
GA1093725079Medicare PIN
GA000153821AMedicaid