Provider Demographics
NPI:1568516086
Name:LUCKEY, ANDREW III (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:LUCKEY
Suffix:III
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 1:1189 SWALLOW LN
Mailing Address - Street 2:STE 201
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-3157
Mailing Address - Country:US
Mailing Address - Phone:805-577-7977
Mailing Address - Fax:805-577-0745
Practice Address - Street 1:2650 JONES WAY
Practice Address - Street 2:SUITE 2
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1203
Practice Address - Country:US
Practice Address - Phone:805-577-7977
Practice Address - Fax:805-577-0745
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69654174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA69654OtherSTATE LICENSE
CAI36128Medicare UPIN