Provider Demographics
NPI:1861487068
Name:WIBOWO, LUKE (MD)
Entity Type:Individual
Prefix:
First Name:LUKE
Middle Name:
Last Name:WIBOWO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ACHMAD
Other - Middle Name:
Other - Last Name:WIBOWO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 20452
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-0452
Mailing Address - Country:US
Mailing Address - Phone:614-457-8180
Mailing Address - Fax:614-583-3300
Practice Address - Street 1:1 WYOMING ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2722
Practice Address - Country:US
Practice Address - Phone:937-208-2978
Practice Address - Fax:937-208-6137
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.068054207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0338469Medicaid
OH0817624Medicare PIN
WI0817623Medicare PIN
WI0817623Medicare PIN