Provider Demographics
NPI:1619904711
Name:LUCKETT, MICHAEL E (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:E
Last Name:LUCKETT
Suffix:
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 1:1401 25TH ST S
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-5183
Mailing Address - Country:US
Mailing Address - Phone:406-731-8888
Mailing Address - Fax:406-731-8888
Practice Address - Street 1:1401 25TH ST S
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-5183
Practice Address - Country:US
Practice Address - Phone:406-731-8888
Practice Address - Fax:406-731-8888
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT6534207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0027047Medicaid
MT0148586OtherWASHINGTON L & I
MT000096780OtherBLUE CROSS BLUE SHIELD
MT184609700OtherFEDERAL WORK COMP
MT200039916OtherRAILROAD MEDICARE
MT810347861OtherCHAMPUS
MT810347861010OtherEBMS
MT0232060001Medicare NSC
MT810347861OtherCHAMPUS
MT000096780OtherBLUE CROSS BLUE SHIELD