Provider Demographics
NPI:1205971140
Name:LUCKEY, ANDREW EDWARD JR (MD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:EDWARD
Last Name:LUCKEY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ANDREW
Other - Middle Name:EDWARD
Other - Last Name:LUCKEY
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3580 E IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-2602
Mailing Address - Country:US
Mailing Address - Phone:310-637-8115
Mailing Address - Fax:
Practice Address - Street 1:3580 E IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2602
Practice Address - Country:US
Practice Address - Phone:310-637-8115
Practice Address - Fax:310-900-8828
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC34426207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC34426OtherMEDICAL LICENSE
CAA87731Medicare UPIN