Provider Demographics
NPI:1184744104
Name:LUCKEY, ROBERT E JR (OD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:E
Last Name:LUCKEY
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:2306 GREENBRANCH DR
Practice Address - Street 2:SUITE #102
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544
Practice Address - Country:US
Practice Address - Phone:813-866-4004
Practice Address - Fax:813-866-4005
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-31
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3815152WC0802X
FLOPC3815152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620881900Medicaid
FLU99576Medicare UPIN