Healthcare Provider Details

I. General information

NPI: 1720119068
Provider Name (Legal Business Name): PAUL A LUCKY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 06/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10506 MONTGOMERY RD STE 402
CINCINNATI OH
45242-4489
US

IV. Provider business mailing address

5300 FAR HILLS AVE
DAYTON OH
45429-2381
US

V. Phone/Fax

Practice location:
  • Phone: 513-791-6161
  • Fax: 513-791-4085
Mailing address:
  • Phone: 937-433-7536
  • Fax: 937-433-9612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number35049616
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: