Provider Demographics
NPI:1912943838
Name:LUCKEY, GERALD WALTER (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:WALTER
Last Name:LUCKEY
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 1:336 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:DAVID CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68632-2116
Mailing Address - Country:US
Mailing Address - Phone:402-367-3193
Mailing Address - Fax:402-367-3261
Practice Address - Street 1:336 S 9TH ST
Practice Address - Street 2:
Practice Address - City:DAVID CITY
Practice Address - State:NE
Practice Address - Zip Code:68632-2116
Practice Address - Country:US
Practice Address - Phone:402-367-3193
Practice Address - Fax:402-367-3261
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE12692207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE261797Medicare ID - Type Unspecified
NEE93025Medicare UPIN
NE080073295Medicare PIN
NE097649Medicare ID - Type Unspecified