Provider Demographics
NPI:1417972563
Name:LU, ETHAN NGHIA (MD)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:NGHIA
Last Name:LU
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 1:1850 N CENTRAL AVE
Mailing Address - Street 2:SUITE1600
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-4633
Mailing Address - Country:US
Mailing Address - Phone:602-744-4765
Mailing Address - Fax:602-744-4799
Practice Address - Street 1:1850 N CENTRAL AVE
Practice Address - Street 2:SUITE1600
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-4633
Practice Address - Country:US
Practice Address - Phone:602-744-4765
Practice Address - Fax:602-744-4799
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76637207L00000X
AZ37796207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ307507Medicaid
P00466470OtherMEDICARE RAILROAD
CA00A7666370Medicare ID - Type Unspecified
AZ120532Medicare PIN