=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225001472
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GARY S LUCKMAN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2006
-----------------------------------------------------
Last Update Date | 05/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8329 W SUNRISE BLVD
-----------------------------------------------------
City | PLANTATION
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33322-5405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-627-1617
-----------------------------------------------------
Fax | 954-474-3489
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9500 S DADELAND BLVD STE 200
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33156-2866
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-530-3820
-----------------------------------------------------
Fax | 305-675-3378
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | ME0016181
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 01096190A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------