Provider Demographics
NPI:1043576358
Name:JERRY L LUGGER MD PA
Entity Type:Organization
Organization Name:JERRY L LUGGER MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:LUGGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-540-1755
Mailing Address - Street 1:461 WESTPARK WAY
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76040-3957
Mailing Address - Country:US
Mailing Address - Phone:817-540-1755
Mailing Address - Fax:817-685-7774
Practice Address - Street 1:461 WESTPARK WAY
Practice Address - Street 2:
Practice Address - City:EULESS
Practice Address - State:TX
Practice Address - Zip Code:76040-3957
Practice Address - Country:US
Practice Address - Phone:817-540-1755
Practice Address - Fax:817-685-7774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-11
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG2762261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB24512Medicare UPIN