Basic Information
| Provider Information | |||||||||
| NPI: | 1720344534 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUCA | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | CENTRALIZED CREDENTIALS & PRIVILEGING DIRECTORATE | ||||||||
| Address2: | 554 KEILY STREET | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322123049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7579537550 | ||||||||
| FaxNumber: | 7579530090 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 JOHN PAUL JONES CIR | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237082111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7579533149 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2012 | ||||||||
| LastUpdateDate: | 11/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | L200550772430 | FL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RP1001X | 0102203537 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No ID Information.