Provider Demographics
NPI:1508008772
Name:LUCKEY, LISA R (DO)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:R
Last Name:LUCKEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:13644 WALSINGHAM RD
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33774-3532
Mailing Address - Country:US
Mailing Address - Phone:727-595-2519
Mailing Address - Fax:727-631-0916
Practice Address - Street 1:13644 WALSINGHAM RD
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33774-3532
Practice Address - Country:US
Practice Address - Phone:727-595-2519
Practice Address - Fax:727-631-0916
Is Sole Proprietor?:No
Enumeration Date:2009-04-02
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS10452207RG0100X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2013366OtherCOVENTRY
FL21924002OtherWELLMED
FL5799464OtherCIGNA
FL119460600Medicaid
FL21924001OtherWELLMED
FL232988OtherUNIVERSAL
FL9269370OtherAETNA
FL342337OtherAVMED
FLBZ100ZMedicare PIN