Provider Demographics
NPI:1477536746
Name:LUXENBERG, NINA L (MD)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:L
Last Name:LUXENBERG
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 1:655 W 8TH ST # C90
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-6511
Mailing Address - Country:US
Mailing Address - Phone:904-244-9448
Mailing Address - Fax:904-244-2116
Practice Address - Street 1:655 W 8TH ST # C90
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-244-9448
Practice Address - Fax:904-244-2116
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL822092085R0202X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01098664OtherRAILROAD
FL14L4COtherBLUE CROSS AND BLUE SHIELD
FL005546000Medicaid
FL14L4COtherBLUE CROSS AND BLUE SHIELD