Provider Demographics
NPI:1740269406
Name:LUBA, KELLY M (DO)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:LUBA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:20940 N TATUM BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-7273
Mailing Address - Country:US
Mailing Address - Phone:480-607-0060
Mailing Address - Fax:480-607-5809
Practice Address - Street 1:20940 N TATUM BLVD STE 300
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-7273
Practice Address - Country:US
Practice Address - Phone:480-607-0060
Practice Address - Fax:480-607-5809
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ3853207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ790809Medicaid
AZ790809Medicaid
AZZ103968Medicare PIN