Provider Demographics
NPI:1457327744
Name:LUBERA, RICHARD J (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:J
Last Name:LUBERA
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 1:12296 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3516
Mailing Address - Country:US
Mailing Address - Phone:586-751-5720
Mailing Address - Fax:586-751-2206
Practice Address - Street 1:12296 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3516
Practice Address - Country:US
Practice Address - Phone:586-751-5720
Practice Address - Fax:586-751-2206
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301024564207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB44001OtherRR MEDICARE
MI0501632OtherBLUE CROSS
MI2724850Medicaid
MI2724850Medicaid
MI0501632OtherBLUE CROSS