Provider Demographics
NPI:1215415385
Name:DUBEROW, LUCAS
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:
Last Name:DUBEROW
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 1:6700 WASHINGTON AVE S
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3405
Mailing Address - Country:US
Mailing Address - Phone:800-328-8602
Mailing Address - Fax:952-285-3980
Practice Address - Street 1:15660 SW PACIFIC HWY STE A5
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-3556
Practice Address - Country:US
Practice Address - Phone:503-968-6445
Practice Address - Fax:503-968-8968
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
237600000X
ORHAS-P-10145077237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter