MEDICARE: MARY ELLEN JOAN LUCHETTI M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	044009	GA
2	174400000X	Specialist	28963	AZ
3	207N00000X	Dermatology Physician	103253	MT
4	207N00000X	Dermatology Physician	G65392	CA
5	207N00000X	Dermatology Physician	MD2006-0021	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679565964
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ELLEN JOAN LUCHETTI M.D.

Provider Business Mailing Address
First Line	:	1021 MEDICAL ARTS AVE NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87102-2708
Country	:	US
Telephone Number	:	505-272-6222
Fax Number	:	505-272-6228

Provider Business Practice Location Address
First Line	:	1021 MEDICAL ARTS AVE NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87102-2708
Country	:	US
Telephone Number	:	505-272-6222
Fax Number	:	505-272-6228

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2005
Last Update Date	:	09/17/2024

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Directions to “ MARY ELLEN JOAN LUCHETTI M.D.” Practice Location

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