Provider Demographics
NPI:1518287739
Name:LUKBAN, MINETTE CRUZ (MD)
Entity Type:Individual
Prefix:
First Name:MINETTE
Middle Name:CRUZ
Last Name:LUKBAN
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 1:500 SW RAMSEY AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5554
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 SW RAMSEY AVE
Practice Address - Street 2:C/O HOSPITALIST
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5554
Practice Address - Country:US
Practice Address - Phone:914-563-5344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-10
Last Update Date:2017-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD150839207R00000X
WAMD60693541207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1518287739Medicaid