Provider Demographics
NPI:1073617262
Name:LUK, SELENE M (DO)
Entity Type:Individual
Prefix:MS
First Name:SELENE
Middle Name:M
Last Name:LUK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1902 BAYVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94002-1617
Mailing Address - Country:US
Mailing Address - Phone:415-297-5096
Mailing Address - Fax:
Practice Address - Street 1:777 E SANTA CLARA ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-1934
Practice Address - Country:US
Practice Address - Phone:408-977-4550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDOS-12382084P0800X, 2084P0804X
CA20A96432084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI1073617262-03Medicaid
HI1073617262-04Medicaid
HI1073617262-01Medicaid
HI1073617262-02Medicaid