Provider Demographics
NPI:1790763092
Name:LUKEN, THERESA L (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:L
Last Name:LUKEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 713256
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43271-0001
Mailing Address - Country:US
Mailing Address - Phone:440-777-6017
Mailing Address - Fax:440-777-6940
Practice Address - Street 1:4300 CLIME RD
Practice Address - Street 2:SUITE 110
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-6491
Practice Address - Country:US
Practice Address - Phone:614-308-9066
Practice Address - Fax:614-308-0028
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-063730207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4014463Medicare PIN
F34265Medicare UPIN
OH4014462Medicare PIN