Provider Demographics
NPI:1922138460
Name:LEUCK, JO A (MD)
Entity Type:Individual
Prefix:DR
First Name:JO
Middle Name:A
Last Name:LEUCK
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:PO BOX 650823
Mailing Address - Street 2:DEPT 41534
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0823
Mailing Address - Country:US
Mailing Address - Phone:817-702-3431
Mailing Address - Fax:405-341-9217
Practice Address - Street 1:1301 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2122
Practice Address - Country:US
Practice Address - Phone:817-451-4208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC127719207P00000X
NC2008-00764207P00000X
TXP8798207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2008-00764OtherSTATE LICENSE
SCN0076JMedicaid
NC5909993Medicaid
TX267279YN9SMedicare PIN
SCN0076JMedicaid