Provider Demographics
NPI:1124223532
Name:STANLEY LUKSENBURG
Entity Type:Organization
Organization Name:STANLEY LUKSENBURG
Other - Org Name:FAIRVIEW PODIATRY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:LUKSENBURG
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:440-356-1118
Mailing Address - Street 1:21475 LORAIN RD
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-2124
Mailing Address - Country:US
Mailing Address - Phone:440-356-1118
Mailing Address - Fax:
Practice Address - Street 1:21475 LORAIN RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-2124
Practice Address - Country:US
Practice Address - Phone:440-356-1118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-16
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002120213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0577620Medicaid
OHFA9206771Medicare ID - Type Unspecified