Basic Information
| Provider Information | |||||||||
| NPI: | 1811003130 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUCKER | ||||||||
| FirstName: | J DONALD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 714328 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432714328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003541985 | ||||||||
| FaxNumber: | 4403504938 | ||||||||
| Practice Location | |||||||||
| Address1: | 9485 MENTOR AVENUE | ||||||||
| Address2: | #101 | ||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402055800 | ||||||||
| FaxNumber: | 4402055801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 04/04/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35-023870 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0197059 | 05 | OH | MEDICAID |