Healthcare Provider Details

I. General information

NPI: 1194107573
Provider Name (Legal Business Name): ZACHARY PAUL LUCHTEFELD D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2015
Last Update Date: 01/06/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 S CENTER ST
MARYVILLE IL
62062-5401
US

IV. Provider business mailing address

2401 S CENTER ST
MARYVILLE IL
62062-5401
US

V. Phone/Fax

Practice location:
  • Phone: 618-344-3046
  • Fax: 618-344-5284
Mailing address:
  • Phone: 618-344-3046
  • Fax: 618-344-5284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2015018601
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036145117
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: