Provider Demographics
NPI:1114938495
Name:LUCKETT, JAMES N (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:N
Last Name:LUCKETT
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 1:2020 E OAKLAND PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33306-1106
Mailing Address - Country:US
Mailing Address - Phone:954-566-2160
Mailing Address - Fax:954-565-0876
Practice Address - Street 1:2020 E OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1106
Practice Address - Country:US
Practice Address - Phone:954-566-2160
Practice Address - Fax:954-566-2180
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78115207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBL5578515OtherDEA REGISTRATION NUMBER
FL46729QMedicare UPIN