Provider Demographics
NPI:1598335200
Name:LUTHULI, KEITH
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:LUTHULI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2587 MILAN ST
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18045-5796
Mailing Address - Country:US
Mailing Address - Phone:215-873-6323
Mailing Address - Fax:
Practice Address - Street 1:1700 ST LUKES BLVD OFC BUILDING
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18045-5670
Practice Address - Country:US
Practice Address - Phone:484-526-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-26
Last Update Date:2021-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT224357207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty