Provider Demographics
NPI:1326315763
Name:DMITRI N. LUKE, D.P.M. L.L.C.
Entity Type:Organization
Organization Name:DMITRI N. LUKE, D.P.M. L.L.C.
Other - Org Name:MONTVALE PODIATRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DMITRI
Authorized Official - Middle Name:N
Authorized Official - Last Name:LUKE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:201-573-0555
Mailing Address - Street 1:26 N KINDERKAMACK RD
Mailing Address - Street 2:
Mailing Address - City:MONTVALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07645-2109
Mailing Address - Country:US
Mailing Address - Phone:201-573-0555
Mailing Address - Fax:201-476-1349
Practice Address - Street 1:26 N KINDERKAMACK RD
Practice Address - Street 2:
Practice Address - City:MONTVALE
Practice Address - State:NJ
Practice Address - Zip Code:07645-2109
Practice Address - Country:US
Practice Address - Phone:201-573-0555
Practice Address - Fax:201-476-1349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00295700261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ175978OtherMEDICARE PTAN