Provider Demographics
NPI:1174796650
Name:LUCKY CARE MEDICAL, PC
Entity type:Organization
Organization Name:LUCKY CARE MEDICAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-876-8590
Mailing Address - Street 1:13876 QUEENS BLVD FL 1
Mailing Address - Street 2:
Mailing Address - City:BRIARWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435-2930
Mailing Address - Country:US
Mailing Address - Phone:718-850-6345
Mailing Address - Fax:718-559-4895
Practice Address - Street 1:2108 2ND AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-3731
Practice Address - Country:US
Practice Address - Phone:212-876-8590
Practice Address - Fax:212-360-1844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY167799207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01029056Medicaid
NYBL0719320OtherDEA
NYBL0719320OtherDEA
NYBL0719320OtherDEA