Provider Demographics
NPI:1790913002
Name:LUA, ALFRED DINGLASAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ALFRED
Middle Name:DINGLASAN
Last Name:LUA
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 1:13570 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:GA
Mailing Address - Zip Code:30752-2012
Mailing Address - Country:US
Mailing Address - Phone:706-956-2665
Mailing Address - Fax:706-657-2958
Practice Address - Street 1:13570 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:GA
Practice Address - Zip Code:30752-2012
Practice Address - Country:US
Practice Address - Phone:706-956-2665
Practice Address - Fax:706-657-2958
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMDR-5674207R00000X
HIMD-16536207R00000X
GA071722207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000211956AMedicaid