1427290055 NPI number — DR. LUKE A JAKUBOWSKI M.D.

Table of content: DR. LUKE A JAKUBOWSKI M.D. (NPI 1427290055)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427290055 NPI number — DR. LUKE A JAKUBOWSKI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JAKUBOWSKI
Provider First Name:
LUKE
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427290055
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2530 CHICAGO AVENUE SOUTH
Provider Second Line Business Mailing Address:
CHILDRENS SPECIALTY CENTER SUITE 450
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-874-1292
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3011 S 56TH ST
Provider Second Line Business Practice Location Address:
APT 11
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53219-3182
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-359-6964
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/27/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207YP0228X , with the licence number:  59156 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 103597600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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