Provider Demographics
NPI:1669464210
Name:LLUSCO, JUAN (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:LLUSCO
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:PO BOX 71608
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-1011
Mailing Address - Country:US
Mailing Address - Phone:480-206-7319
Mailing Address - Fax:
Practice Address - Street 1:1641 E OSBORN RD
Practice Address - Street 2:SUITE 3
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7146
Practice Address - Country:US
Practice Address - Phone:480-206-7319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2013-05-31
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-10
Provider Licenses
StateLicense IDTaxonomies
AZAZ31758208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ805872Medicaid