Healthcare Provider Details

I. General information

NPI: 1598335200
Provider Name (Legal Business Name): KEITH LUTHULI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2021
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 WILFORD HALL LOOP, JBSA LACKLAND AFB, TX 78236
APO AA
78236
US

IV. Provider business mailing address

HWY 90 AND SW MILITARY ROAD LACKLAND AFB, TX
APO AA
78236
US

V. Phone/Fax

Practice location:
  • Phone: 215-873-6323
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD485767
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMT224357
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: