Provider Demographics
NPI:1366648081
Name:NYSTROM, LUKAS M (MD)
Entity Type:Individual
Prefix:
First Name:LUKAS
Middle Name:M
Last Name:NYSTROM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LOYOLA UNIVERSITY MEDICAL CENTER
Mailing Address - Street 2:2160 SOUTH FIRST AVE.
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:319-541-0954
Mailing Address - Fax:
Practice Address - Street 1:LOYOLA UNIVERSITY MEDICAL CENTER
Practice Address - Street 2:2160 SOUTH FIRST AVENUE
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:319-541-0954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2013-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR8020207X00000X
IL036131887207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery