Provider Demographics
NPI:1679565964
Name:LUCHETTI, MARY ELLEN JOAN (MD)
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:JOAN
Last Name:LUCHETTI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 MEDICAL ARTS AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2708
Mailing Address - Country:US
Mailing Address - Phone:505-272-6222
Mailing Address - Fax:505-272-6228
Practice Address - Street 1:1021 MEDICAL ARTS AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2708
Practice Address - Country:US
Practice Address - Phone:505-272-6222
Practice Address - Fax:505-272-6228
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28963174400000X
GA044009207N00000X
NMMD2006-0021207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003137516Medicaid
GA003137516Medicaid
GA07BBSSBMedicare ID - Type Unspecified
GAF26224Medicare UPIN