MEDICARE: DR. GARY J LUCKASEN M.D.

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician	20789	CO
2	207RC0000X	Cardiovascular Disease Physician	19652	NE

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00970356	OTHER	NE	MEDICARE RAILROAD
4	P00910572	OTHER	CO	MEDICARE RAILROAD

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1063418572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY J LUCKASEN M.D.

Provider Business Mailing Address
First Line	:	2121 E HARMONY RD
Second Line	:	SUITE 100
City	:	FORT COLLINS
State	:	CO
Zip	:	80528-3400
Country	:	US
Telephone Number	:	970-221-1000
Fax Number	:	970-297-6860

Provider Business Practice Location Address
First Line	:	2121 E HARMONY RD
Second Line	:	UNIT 100
City	:	FORT COLLINS
State	:	CO
Zip	:	80528-3401
Country	:	US
Telephone Number	:	970-221-1000
Fax Number	:	970-297-6860

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	06/12/2014

2121 E HARMONY RD UNIT 100
FORT COLLINS, CO
80528-3401

Practice Phone: 970-221-1000
Practice Fax: 970-297-6886