Provider Demographics
NPI:1104180124
Name:LUKBAN, MARINA D (MSED)
Entity Type:Individual
Prefix:MRS
First Name:MARINA
Middle Name:D
Last Name:LUKBAN
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940 MAYFLOWER AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-4007
Mailing Address - Country:US
Mailing Address - Phone:917-749-5334
Mailing Address - Fax:
Practice Address - Street 1:1940 MAYFLOWER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-4007
Practice Address - Country:US
Practice Address - Phone:917-749-5334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-25
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY809457174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY273442291OtherDRIVER'S LICENSE
NY0543254OtherDOE EMPLOYEE NUMBER