Healthcare Provider Details

I. General information

NPI: 1467696963
Provider Name (Legal Business Name): LUCKEY CONNOR REED M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2009
Last Update Date: 01/12/2022
Certification Date: 01/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1617 N CALIFORNIA ST STE 2D
STOCKTON CA
95204-6117
US

IV. Provider business mailing address

301 RIDGEWOOD DR
GEORGETOWN TX
78628-8366
US

V. Phone/Fax

Practice location:
  • Phone: 209-933-9888
  • Fax: 209-933-9988
Mailing address:
  • Phone: 832-798-3186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License NumberR4891
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberBP1-0034783
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License NumberC175206
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: