Provider Demographics
NPI:1407996069
Name:LUKSENBURG, STANLEY (DPM)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:
Last Name:LUKSENBURG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21724 LORAIN RD
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-3334
Mailing Address - Country:US
Mailing Address - Phone:440-356-1118
Mailing Address - Fax:216-464-9242
Practice Address - Street 1:21724 LORAIN RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-3334
Practice Address - Country:US
Practice Address - Phone:440-356-1118
Practice Address - Fax:216-464-9242
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36 002120213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0577620Medicaid
OH0577620Medicaid