Provider Demographics
NPI:1104366467
Name:LUARDO, IAN CESAR JR
Entity Type:Individual
Prefix:
First Name:IAN CESAR JR
Middle Name:
Last Name:LUARDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4922 LASALLE RD
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20782-3302
Mailing Address - Country:US
Mailing Address - Phone:240-520-3345
Mailing Address - Fax:
Practice Address - Street 1:4922 LASALLE RD
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20782-3302
Practice Address - Country:US
Practice Address - Phone:301-864-2333
Practice Address - Fax:877-828-2060
Is Sole Proprietor?:No
Enumeration Date:2017-03-06
Last Update Date:2017-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD26387225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4374045-00Medicaid
MD1447657507OtherNPI
MD1447657507OtherNPI