Healthcare Provider Details

I. General information

NPI: 1780894725
Provider Name (Legal Business Name): DAVID J LUTCHKA PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S EAST AVE
JACKSON MI
49201-2412
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-2146
  • Fax:
Mailing address:
  • Phone: 800-653-6568
  • Fax: 313-876-1305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601003333
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: