Provider Demographics
NPI:1720119068
Name:LUCKY, PAUL A (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:A
Last Name:LUCKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:5300 FAR HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2381
Mailing Address - Country:US
Mailing Address - Phone:937-433-7536
Mailing Address - Fax:937-433-9612
Practice Address - Street 1:10506 MONTGOMERY RD STE 402
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45242-4489
Practice Address - Country:US
Practice Address - Phone:513-791-6161
Practice Address - Fax:513-791-4085
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35049616207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0538912Medicaid
OHCO2590Medicare UPIN
OHH347780Medicare PIN