Provider Demographics
NPI:1447357116
Name:LUCZAK, KENNETH DAVID (PT)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:DAVID
Last Name:LUCZAK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5915 SUGAR GROVE RD
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-9271
Mailing Address - Country:US
Mailing Address - Phone:740-541-0099
Mailing Address - Fax:
Practice Address - Street 1:1122 TAYLOR ST
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-2658
Practice Address - Country:US
Practice Address - Phone:740-588-2182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT10054225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2620186Medicaid
OH4169621Medicare ID - Type Unspecified