Provider Demographics
NPI:1508919929
Name:LUU, JOHNNY (MD)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:LUU
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 1:1190 BAKER ST
Mailing Address - Street 2:P.O BOX 100
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-4108
Mailing Address - Country:US
Mailing Address - Phone:714-668-2540
Mailing Address - Fax:714-668-2510
Practice Address - Street 1:1190 BAKER ST
Practice Address - Street 2:100
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4108
Practice Address - Country:US
Practice Address - Phone:714-668-2540
Practice Address - Fax:714-668-2510
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA90179208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA90179OtherMEDICAL LICENSE
CABL9657252OtherDEA LICENSE