Provider Demographics
NPI:1497955132
Name:JESUS LUA, MD, A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:JESUS LUA, MD, A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESUS
Authorized Official - Middle Name:
Authorized Official - Last Name:LUA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-985-5784
Mailing Address - Street 1:360 E 7TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-6701
Mailing Address - Country:US
Mailing Address - Phone:909-985-5784
Mailing Address - Fax:909-985-7844
Practice Address - Street 1:360 E 7TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-6701
Practice Address - Country:US
Practice Address - Phone:909-985-5784
Practice Address - Fax:909-985-7844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50698208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1992776108OtherINDIVIDUAL NPI
CA00A506980Medicaid
CA00A506980Medicaid
CA00A506981Medicare PIN