Basic Information
| Provider Information | |||||||||
| NPI: | 1801829379 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUCKTONG | ||||||||
| FirstName: | EKACHAI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3101 LATROBE DR | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282114849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043767362 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3101 LATROBE DR | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282114849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043767362 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 200000880 | NC | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 89127A5 | 05 | NC | MEDICAID | N00880 | 05 | SC | MEDICAID |