Provider Demographics
NPI:1720333768
Name:LUY, MICHAEL WATA (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WATA
Last Name:LUY
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 3868
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47737-3868
Mailing Address - Country:US
Mailing Address - Phone:812-450-6879
Mailing Address - Fax:812-858-4545
Practice Address - Street 1:421 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47713-1227
Practice Address - Country:US
Practice Address - Phone:812-426-9372
Practice Address - Fax:812-858-4545
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036132602207R00000X, 261QM2500X
IN01077251A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN257900120Medicare PIN