MEDICARE: THOMAS JORDAN LUCAK MD

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician	27538	MS

General Provider Information

NPI Number	:	1598185563
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS JORDAN LUCAK MD

Provider Business Mailing Address
First Line	:	6300 E LAKE BLVD STE 301
Second Line	:
City	:	VANCLEAVE
State	:	MS
Zip	:	39565-6771
Country	:	US
Telephone Number	:	228-230-2663
Fax Number	:

Provider Business Practice Location Address
First Line	:	6300 E LAKE BLVD STE 201
Second Line	:
City	:	VANCLEAVE
State	:	MS
Zip	:	39565-6771
Country	:	US
Telephone Number	:	228-230-2663
Fax Number	:	228-546-3257

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

Provider Enumeration Date	:	04/17/2014
Last Update Date	:	08/14/2020

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