Provider Demographics
NPI:1700881984
Name:LUKETIC, DAVOR A (MD)
Entity Type:Individual
Prefix:MR
First Name:DAVOR
Middle Name:A
Last Name:LUKETIC
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 1:2000 A SOUTHBRIDGE PARKWAY
Mailing Address - Street 2:STE 300
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209
Mailing Address - Country:US
Mailing Address - Phone:205-871-4274
Mailing Address - Fax:205-871-4301
Practice Address - Street 1:701 PRINCETON AVENUE
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35211
Practice Address - Country:US
Practice Address - Phone:205-783-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL112242085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009941716Medicaid
AL122689Medicaid
AL511-56300OtherBLUE CROSS
AL051539419OtherBLUE CROSS
AL009942178Medicaid
AL1610041OtherUHC
AL170544Medicaid
AL051540337OtherBLUE CROSS
AL105703Medicaid
AL051012861OtherBLUE CROSS
AL4006199OtherAETNA
AL511-09781OtherBLUE CROSS
AL051526312OtherBLUE CROSS
AL000012861Medicaid
AL009992495Medicaid
AL515-94619OtherBLUE CROSS
AL511-09781OtherBLUE CROSS
AL009942178Medicaid
AL170544Medicaid
AL102I309191Medicare PIN