Healthcare Provider Details

I. General information

NPI: 1447322367
Provider Name (Legal Business Name): MITCHELL ALAN LUCHANSKY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 10/22/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

267 OLD MOODY BLVD
PALM COAST FL
32164-2470
US

IV. Provider business mailing address

267 OLD MOODY BLVD
PALM COAST FL
32164-2470
US

V. Phone/Fax

Practice location:
  • Phone: 386-313-5752
  • Fax: 386-313-5801
Mailing address:
  • Phone: 386-313-5752
  • Fax: 386-313-5801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberG55527
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberME77530
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: