Healthcare Provider Details

I. General information

NPI: 1619332475
Provider Name (Legal Business Name): JOHN D LUCK M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: J.D. LUCK

II. Dates (important events)

Enumeration Date: 12/22/2015
Last Update Date: 08/05/2025
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 OLD COURT RD DEPT OF
RANDALLSTOWN MD
21133-5103
US

IV. Provider business mailing address

303 E NICOLLET BLVD SUITE 330
BURNSVILLE MN
55337
US

V. Phone/Fax

Practice location:
  • Phone: 410-521-2200
  • Fax: 410-496-7530
Mailing address:
  • Phone: 952-435-0177
  • Fax: 952-435-6287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number77877
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberD90135
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: