Provider Demographics
NPI:1801813571
Name:LUZ, AILEEN L (MD)
Entity Type:Individual
Prefix:
First Name:AILEEN
Middle Name:L
Last Name:LUZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 BROADWAY N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-6704
Mailing Address - Country:US
Mailing Address - Phone:701-234-2900
Mailing Address - Fax:701-234-2996
Practice Address - Street 1:2601 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-6704
Practice Address - Country:US
Practice Address - Phone:701-234-2900
Practice Address - Fax:701-234-2996
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN41674207Q00000X
ND9203207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G88735Medicare UPIN
NDN22251Medicare PIN