Provider Demographics
NPI:1306821020
Name:LUECKE, NICOLE M (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:M
Last Name:LUECKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 MEDICAL PKWY
Mailing Address - Street 2:SUITE 370
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7992
Mailing Address - Country:US
Mailing Address - Phone:410-571-9700
Mailing Address - Fax:410-571-9710
Practice Address - Street 1:2003 MEDICAL PKWY
Practice Address - Street 2:SUITE 370
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7992
Practice Address - Country:US
Practice Address - Phone:410-571-9700
Practice Address - Fax:410-571-9710
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0054454174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG96929Medicare UPIN