Provider Demographics
NPI:1114921525
Name:LUCKASEN, JOHN R (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:R
Last Name:LUCKASEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:4242 FARNAM ST
Mailing Address - Street 2:STE 360
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-2850
Mailing Address - Country:US
Mailing Address - Phone:402-552-2555
Mailing Address - Fax:402-552-2573
Practice Address - Street 1:4242 FARNAM ST
Practice Address - Street 2:STE 360
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68131-2850
Practice Address - Country:US
Practice Address - Phone:402-552-2555
Practice Address - Fax:402-552-2573
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE12194207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE139381XXOtherPREFERRED CARE
IA91864OtherBLUE SHIELD
NE47062325613Medicaid
PA501880OtherBLUE SHIELD
SD0001967OtherBLUE SHIELD
NE00686OtherBLUE SHIELD
IA0918649Medicaid
NE0300003OtherUNITED HEALTH CARE
SD7787680Medicaid
NE139381XXOtherPREFERRED CARE
NE00686OtherBLUE SHIELD