Healthcare Provider Details

I. General information

NPI: 1700848611
Provider Name (Legal Business Name): WILLIAM BRIAN LUCHTEFELD NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 01/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10600 LEWIS AND CLARK BLVD
SAINT LOUIS MO
63136-6005
US

IV. Provider business mailing address

2910 GILBERT LN
ALTON IL
62002-5504
US

V. Phone/Fax

Practice location:
  • Phone: 314-286-6988
  • Fax: 314-868-2561
Mailing address:
  • Phone: 618-465-7470
  • Fax: 314-868-2561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number101018
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: