Provider Demographics
NPI:1083608699
Name:JURACEK, LYNN LEROY (MD)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:LEROY
Last Name:JURACEK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14239 W BELL RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-2469
Mailing Address - Country:US
Mailing Address - Phone:623-544-7755
Mailing Address - Fax:623-544-8665
Practice Address - Street 1:14239 W BELL RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-2469
Practice Address - Country:US
Practice Address - Phone:623-544-7755
Practice Address - Fax:623-544-8665
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30022207N00000X, 207ND0101X, 207NI0002X, 207NS0135X, 207ND0900X, 207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ71098Medicare PIN
AZZ79179Medicare PIN
E91085Medicare UPIN
AZZ70967Medicare PIN