Provider Demographics
NPI:1932113545
Name:LUKISH, JEFFREY R (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:R
Last Name:LUKISH
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:PO BOX 744785
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-4785
Mailing Address - Country:US
Mailing Address - Phone:202-476-5000
Mailing Address - Fax:
Practice Address - Street 1:111 MICHIGAN AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2916
Practice Address - Country:US
Practice Address - Phone:202-476-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD320632086S0120X
MDD00446922086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD104423158OtherCAQH PROVIDER ID
MD697801101Medicaid
MD180538YVEMedicare PIN