Provider Demographics
NPI:1982717765
Name:LU, JACK I (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:I
Last Name:LU
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 1:400 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-4506
Mailing Address - Country:US
Mailing Address - Phone:240-566-4723
Mailing Address - Fax:
Practice Address - Street 1:400 W 7TH ST
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701
Practice Address - Country:US
Practice Address - Phone:240-566-4722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101240453207R00000X
MDD65008207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1982717765Medicaid
VAP00417036OtherMEDICARE RAILROAD CARRIER
VAP00417036OtherMEDICARE RAILROAD CARRIER