Healthcare Provider Details

I. General information

NPI: 1396056834
Provider Name (Legal Business Name): JEAN-PAUL C. LUCKE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2010
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4897 YORK ROAD 278
BUCKINGHAM PA
18912
US

IV. Provider business mailing address

PO BOX 829641
PHILADELPHIA PA
19182-0001
US

V. Phone/Fax

Practice location:
  • Phone: 215-794-7471
  • Fax: 215-794-2576
Mailing address:
  • Phone: 267-370-5296
  • Fax: 215-230-3725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number25MB10306200
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number53143
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS015781
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: