Provider Demographics
NPI:1659494557
Name:LUECKER, STEPHANI SIMON (DO)
Entity Type:Individual
Prefix:
First Name:STEPHANI
Middle Name:SIMON
Last Name:LUECKER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:STEPHANI
Other - Middle Name:L
Other - Last Name:SIMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 660446
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91066-0446
Mailing Address - Country:US
Mailing Address - Phone:626-447-0296
Mailing Address - Fax:626-447-6057
Practice Address - Street 1:1145 W REDONDO BEACH BLVD
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-3528
Practice Address - Country:US
Practice Address - Phone:310-538-6629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-08
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11735207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A11735OtherMEDICAL LICENSE