Provider Demographics
NPI:1811953524
Name:LUSKO, MICHAEL WALTER (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WALTER
Last Name:LUSKO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9824 SCOTT MILL RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-5845
Mailing Address - Country:US
Mailing Address - Phone:904-737-2314
Mailing Address - Fax:904-236-6581
Practice Address - Street 1:800 PRUDENTIAL DR
Practice Address - Street 2:SUITE 713
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8202
Practice Address - Country:US
Practice Address - Phone:904-396-5682
Practice Address - Fax:904-346-0864
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS3713207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL82132OtherBLUE CROSS
GA000762748CMedicaid
FL069703600Medicaid
P00428011Medicare PIN
FL82132OtherBLUE CROSS
FL069703600Medicaid