Provider Demographics
NPI:1417408766
Name:LUCKY, TYRONE JR
Entity Type:Individual
Prefix:MR
First Name:TYRONE
Middle Name:
Last Name:LUCKY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7334 NE JACKSONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34479-5334
Mailing Address - Country:US
Mailing Address - Phone:321-438-3338
Mailing Address - Fax:
Practice Address - Street 1:7334 NE JACKSONVILLE RD APT 160A
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34479-8327
Practice Address - Country:US
Practice Address - Phone:321-438-3338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL220300390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program