Provider Demographics
NPI:1326033804
Name:LUCKEY, DOMINIQUE LANELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMINIQUE
Middle Name:LANELLE
Last Name:LUCKEY
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 1:5823 YORK BLVD
Mailing Address - Street 2:#1
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-2634
Mailing Address - Country:US
Mailing Address - Phone:323-255-3437
Mailing Address - Fax:
Practice Address - Street 1:1701 E CESAR CHAVEZ AVE
Practice Address - Street 2:SUITE #402
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-2464
Practice Address - Country:US
Practice Address - Phone:323-317-9200
Practice Address - Fax:323-317-9206
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2007-10-18
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
CAA69874207VG0400X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A698740OtherBLUE SHIELD
CA00A698740Medicaid
GAP00384423OtherMEDICARE RAILROAD
GAP00384423OtherMEDICARE RAILROAD
CAH81387Medicare UPIN