Provider Demographics
NPI:1518239946
Name:CHARLES A LUXENBERG MD PA
Entity Type:Organization
Organization Name:CHARLES A LUXENBERG MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GWYNN
Authorized Official - Middle Name:F
Authorized Official - Last Name:FISHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-785-6777
Mailing Address - Street 1:2595 TAMPA RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-3130
Mailing Address - Country:US
Mailing Address - Phone:727-785-6777
Mailing Address - Fax:727-785-7102
Practice Address - Street 1:2595 TAMPA RD
Practice Address - Street 2:SUITE A
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3152
Practice Address - Country:US
Practice Address - Phone:727-785-6777
Practice Address - Fax:727-785-7102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME35503156FX1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAL8952447OtherDEA
FLFT59AMedicare PIN