Provider Demographics
NPI:1114959558
Name:LU, WILLIE DY (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIE
Middle Name:DY
Last Name:LU
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 1:320 DARDANELLI LN
Mailing Address - Street 2:SUITE @ 21 B
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-1440
Mailing Address - Country:US
Mailing Address - Phone:408-866-8700
Mailing Address - Fax:
Practice Address - Street 1:320 DARDANELLI LN
Practice Address - Street 2:SUITE @ 21 B
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-1440
Practice Address - Country:US
Practice Address - Phone:408-866-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA495970174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
00A495970OtherPTAN
1114959558OtherNPI
CA0046324Medicaid
1114959558OtherNPI