Provider Demographics
NPI:1932459997
Name:LUCKY, THOMAS L (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
Last Name:LUCKY
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 1:1216 CONSTITUTION AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-4003
Mailing Address - Country:US
Mailing Address - Phone:601-482-2612
Mailing Address - Fax:
Practice Address - Street 1:1216 CONSTITUTION AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4003
Practice Address - Country:US
Practice Address - Phone:601-482-2612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS16225207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine