Provider Demographics
NPI:1689895591
Name:LUCE, DAVID (AA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:LUCE
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:598 THRID STREET
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201
Mailing Address - Country:US
Mailing Address - Phone:478-633-6706
Mailing Address - Fax:478-633-5384
Practice Address - Street 1:777 HEMLOCK STREET
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201
Practice Address - Country:US
Practice Address - Phone:478-633-6706
Practice Address - Fax:478-633-5384
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003518367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA970015867OtherRAILROAD MCR - MCCG
GA100001363AMedicaid
GA100001363AOtherPEACHSTATE CMO - MCCG
GA344351OtherWELLCARE CMO - MCCG
GA100001363AMedicaid
GAP14210Medicare UPIN