Provider Demographics
NPI:1700814647
Name:LUGGER, JERRY LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LEE
Last Name:LUGGER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3061 W SOUTHLAKE BLVD
Mailing Address - Street 2:STE 130
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-0314
Mailing Address - Country:US
Mailing Address - Phone:817-540-1755
Mailing Address - Fax:817-685-7774
Practice Address - Street 1:461 WESTPARK WAY
Practice Address - Street 2:
Practice Address - City:EULESS
Practice Address - State:TX
Practice Address - Zip Code:76040-3957
Practice Address - Country:US
Practice Address - Phone:817-540-1755
Practice Address - Fax:817-685-7774
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2017-02-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXG2762208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP0007P724Medicaid
TXP0007P724Medicaid
TXB24512Medicare UPIN