Healthcare Provider Details

I. General information

NPI: 1679957781
Provider Name (Legal Business Name): MARGARITA LUCKHARDT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2015
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

196 COBBLESTONE DR
MADISON MS
39110-9100
US

V. Phone/Fax

Practice location:
  • Phone: 414-352-3100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number69485
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberV1172
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35434
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: