Provider Demographics
NPI:1275690992
Name:LUO, FREDERIC (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERIC
Middle Name:
Last Name:LUO
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 1108
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86405-1108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 MESQUITE AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5664
Practice Address - Country:US
Practice Address - Phone:928-854-8720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31254207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZG72374Medicare UPIN