Provider Demographics
NPI:1255027546
Name:LUKE W. DEITZ M.D., A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:LUKE W. DEITZ M.D., A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEITZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-428-3705
Mailing Address - Street 1:419 OCEAN PARK BLVD # A
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-3612
Mailing Address - Country:US
Mailing Address - Phone:410-428-3705
Mailing Address - Fax:
Practice Address - Street 1:6101 W CENTINELA AVE STE 170
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-6350
Practice Address - Country:US
Practice Address - Phone:410-428-3705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-11
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty