Provider Demographics
NPI:1659480564
Name:LUTHRA, GIRISH (MBBS)
Entity Type:Individual
Prefix:DR
First Name:GIRISH
Middle Name:
Last Name:LUTHRA
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 SIXTH AVE N
Mailing Address - Street 2:CENTRACARE CLINIC
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2735
Mailing Address - Country:US
Mailing Address - Phone:320-252-5131
Mailing Address - Fax:603-354-5469
Practice Address - Street 1:1200 SIXTH AVE N
Practice Address - Street 2:CENTRACARE CLINIC
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2735
Practice Address - Country:US
Practice Address - Phone:320-252-5131
Practice Address - Fax:603-354-5469
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH11668208600000X
MN106406208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1009114Medicaid
NH30103181Medicaid
NHH67667Medicare UPIN
NHRE6844Medicare ID - Type Unspecified