Provider Demographics
NPI:1770572331
Name:LUCKAY, KENNETH R (DO)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:LUCKAY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4515 BRAMBLETON AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3436
Mailing Address - Country:US
Mailing Address - Phone:540-777-6807
Mailing Address - Fax:855-248-9858
Practice Address - Street 1:4515 BRAMBLETON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3436
Practice Address - Country:US
Practice Address - Phone:540-777-6807
Practice Address - Fax:855-248-9858
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102049893207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005615127Medicaid
VA362206700OtherDEPT OF LABOR
VA441414OtherANTHEM
VA080007664Medicare ID - Type Unspecified
VA080007664Medicare UPIN