Provider Demographics
NPI:1861450348
Name:LUCCHESI, GARY M (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:M
Last Name:LUCCHESI
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 1:6729 MONTE RD
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-8050
Mailing Address - Country:US
Mailing Address - Phone:805-602-0164
Mailing Address - Fax:
Practice Address - Street 1:105 S MAIN ST STE 4
Practice Address - Street 2:
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-9601
Practice Address - Country:US
Practice Address - Phone:805-434-1869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG83924207PE0004X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G839240Medicaid
CAWG83924BMedicare ID - Type Unspecified
CA00G839240Medicaid