Provider Demographics
NPI:1417202268
Name:LUKA, BETSY K (MD)
Entity Type:Individual
Prefix:
First Name:BETSY
Middle Name:K
Last Name:LUKA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4326 W MONTROSE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-2016
Mailing Address - Country:US
Mailing Address - Phone:773-883-9100
Mailing Address - Fax:773-883-0005
Practice Address - Street 1:4326 W MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-2016
Practice Address - Country:US
Practice Address - Phone:773-883-9100
Practice Address - Fax:773-883-0005
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-18
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY265725-1207Q00000X
CT051158207Q00000X
IL036136306207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036136306Medicaid