Provider Demographics
NPI:1134111503
Name:LUBBERS, DAVID JEROME (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JEROME
Last Name:LUBBERS
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:PO BOX 932163
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0001
Mailing Address - Country:US
Mailing Address - Phone:586-412-4000
Mailing Address - Fax:586-412-4100
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-301-2160
Practice Address - Fax:859-301-3932
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY245072085R0202X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0060564Medicaid
OH0592569Medicaid
KY64245079Medicaid
300013439OtherRRMC
OH0060564Medicaid
OH0592569Medicaid
KY3400160Medicare PIN
KY1269616Medicare PIN
KY3313158Medicare PIN
KY64245079Medicaid