Provider Demographics
NPI:1659431096
Name:LUBY, BERNARD JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:JOSEPH
Last Name:LUBY
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 1:4607 MACCORKLE AVE SW STE 206
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1364
Mailing Address - Country:US
Mailing Address - Phone:304-766-1133
Mailing Address - Fax:304-766-1131
Practice Address - Street 1:4607 MACCORKLE AVE SW STE 206
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1364
Practice Address - Country:US
Practice Address - Phone:304-766-1133
Practice Address - Fax:304-766-1136
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV12708207VF0040X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0094699000Medicaid
WVA72340Medicare UPIN
WVLU0564003Medicare ID - Type Unspecified
WV0094699000Medicaid