Provider Demographics
NPI:1760599153
Name:THIEN T LUU MD PA
Entity Type:Organization
Organization Name:THIEN T LUU MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DZUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:LUU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-762-3727
Mailing Address - Street 1:2000 W 21ST
Mailing Address - Street 2:E-2
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101
Mailing Address - Country:US
Mailing Address - Phone:575-762-3726
Mailing Address - Fax:575-762-3727
Practice Address - Street 1:2000 W 21ST
Practice Address - Street 2:E-2
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:575-762-3726
Practice Address - Fax:575-762-3727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM84-70208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM33779Medicaid