Provider Demographics
NPI:1710118302
Name:PREVEDELLO, LUCIANO M (MD)
Entity Type:Individual
Prefix:
First Name:LUCIANO
Middle Name:M
Last Name:PREVEDELLO
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 1:700 ACKERMAN RD STE 570
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1579
Mailing Address - Country:US
Mailing Address - Phone:614-685-1811
Mailing Address - Fax:
Practice Address - Street 1:395 W 12TH AVE
Practice Address - Street 2:RM 460
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1267
Practice Address - Country:US
Practice Address - Phone:614-293-8319
Practice Address - Fax:614-293-6935
Is Sole Proprietor?:No
Enumeration Date:2009-07-31
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH800000092085R0202X
OH35.1281862085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology