Healthcare Provider Details

I. General information

NPI: 1679565964
Provider Name (Legal Business Name): MARY ELLEN JOAN LUCHETTI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 MEDICAL ARTS AVE NE
ALBUQUERQUE NM
87102-2708
US

IV. Provider business mailing address

1021 MEDICAL ARTS AVE NE
ALBUQUERQUE NM
87102-2708
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-6222
  • Fax: 505-272-6228
Mailing address:
  • Phone: 505-272-6222
  • Fax: 505-272-6228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number044009
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number28963
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number103253
License Number StateMT
# 4
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberG65392
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD2006-0021
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: