Provider Demographics
NPI:1962447268
Name:J LUCAS KOBERDA, MD, PHD, NEUROLOGY, LLC
Entity Type:Organization
Organization Name:J LUCAS KOBERDA, MD, PHD, NEUROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAROSLAW
Authorized Official - Middle Name:LUCAS
Authorized Official - Last Name:KOBERDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-877-2802
Mailing Address - Street 1:4838 KERRY FOREST PKWY
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32309-2272
Mailing Address - Country:US
Mailing Address - Phone:850-877-2802
Mailing Address - Fax:850-222-1383
Practice Address - Street 1:4838 KERRY FOREST PKWY
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32309-2272
Practice Address - Country:US
Practice Address - Phone:850-877-2802
Practice Address - Fax:850-222-1383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q0254Medicare PIN