Healthcare Provider Details

I. General information

NPI: 1770748667
Provider Name (Legal Business Name): JEREMY D. LUCKETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2008
Last Update Date: 01/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2851 NEW HARTFORD RD STE A
OWENSBORO KY
42303
US

IV. Provider business mailing address

2851 NEW HARTFORD RD STE A
OWENSBORO KY
42303-1320
US

V. Phone/Fax

Practice location:
  • Phone: 270-240-2305
  • Fax:
Mailing address:
  • Phone: 270-240-2305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number44246
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01073931A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: