Provider Demographics
NPI:1467514265
Name:LU, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
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 1:622 W. DUARTE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007
Mailing Address - Country:US
Mailing Address - Phone:626-254-9010
Mailing Address - Fax:
Practice Address - Street 1:622 W DUARTE RD STE 101
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-9266
Practice Address - Country:US
Practice Address - Phone:626-254-9010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62592207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA180038472OtherMEDICARE RAILROAD
CA00A625920OtherBLUE SHIELD
CA00A625920Medicaid
CAWA62592BMedicare PIN
CA180038472OtherMEDICARE RAILROAD
CAWA62592AMedicare PIN
CAH08330Medicare UPIN