Healthcare Provider Details

I. General information

NPI: 1558556258
Provider Name (Legal Business Name): JESSICA P LUKOWSKI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA P PERRY MD

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 10/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8004 MYRTLE TRACE DR
CONWAY SC
29526-8945
US

IV. Provider business mailing address

PO BOX 2180
CONWAY SC
29528-2180
US

V. Phone/Fax

Practice location:
  • Phone: 843-347-7216
  • Fax: 843-347-7218
Mailing address:
  • Phone: 843-347-7216
  • Fax: 843-234-6990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number33698
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: