Provider Demographics
NPI:1538168075
Name:LUCKY, WILLIAM DAVID SR (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:DAVID
Last Name:LUCKY
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13727 SW 152ND ST
Mailing Address - Street 2:#104
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-1106
Mailing Address - Country:US
Mailing Address - Phone:305-238-3990
Mailing Address - Fax:305-254-6331
Practice Address - Street 1:125 NE 8TH ST
Practice Address - Street 2:SUITE 4
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-4676
Practice Address - Country:US
Practice Address - Phone:305-238-3990
Practice Address - Fax:305-254-6331
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME290492083P0011X
FL0029049174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK5918OtherMEDICARE GROUP PROVIDER N
FLK5918COtherGROUP PTAN FL MEDICARE
FL038136500Medicaid
FL95193YMedicare PIN
FLD63361Medicare UPIN
FLK5918COtherGROUP PTAN FL MEDICARE