Provider Demographics
NPI:1437139813
Name:LUBA, MARK CLINTON (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:CLINTON
Last Name:LUBA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2145 E BASELINE RD # 101
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-1503
Mailing Address - Country:US
Mailing Address - Phone:888-705-8558
Mailing Address - Fax:480-776-0025
Practice Address - Street 1:18555 N 79TH AVE STE B108
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8372
Practice Address - Country:US
Practice Address - Phone:888-705-8558
Practice Address - Fax:480-776-0025
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ26967207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ276049OtherMEDICARE
AZ539869Medicaid
AZZ154561Medicare PIN