Healthcare Provider Details

I. General information

NPI: 1144583188
Provider Name (Legal Business Name): JOHN RICHARD LUKSCH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2012
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 EVERGREEN DR STE 201
GLEN MILLS PA
19342-1053
US

IV. Provider business mailing address

833 CHESTNUT ST STE 520
PHILADELPHIA PA
19107-4430
US

V. Phone/Fax

Practice location:
  • Phone: 267-339-3558
  • Fax: 267-339-3763
Mailing address:
  • Phone: 267-339-7843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOS018364
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number25MB09553700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: