Provider Demographics
NPI:1558397877
Name:SAN, LUKE (MD)
Entity Type:Individual
Prefix:DR
First Name:LUKE
Middle Name:
Last Name:SAN
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 1:202 AGEE ST
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901-2617
Mailing Address - Country:US
Mailing Address - Phone:434-392-6143
Mailing Address - Fax:434-392-3866
Practice Address - Street 1:202 AGEE ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-2617
Practice Address - Country:US
Practice Address - Phone:434-392-6143
Practice Address - Fax:434-392-3866
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101048599207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005849632Medicaid
VA110004643Medicare ID - Type Unspecified
VA005849632Medicaid