Provider Demographics
NPI:1619332475
Name:LUCK, JOHN DYLAN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DYLAN
Last Name:LUCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:J.D.
Other - Middle Name:
Other - Last Name:LUCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5401 OLD COURT RD
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-5103
Mailing Address - Country:US
Mailing Address - Phone:410-521-2200
Mailing Address - Fax:
Practice Address - Street 1:5401 OLD COURT RD DEPT OF
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-5103
Practice Address - Country:US
Practice Address - Phone:410-521-2200
Practice Address - Fax:410-496-7530
Is Sole Proprietor?:No
Enumeration Date:2015-12-22
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDD90135208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program