Healthcare Provider Details

I. General information

NPI: 1679955041
Provider Name (Legal Business Name): LUKE D KILLPACK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2015
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10238 E HAMPTON AVE STE 404
MESA AZ
85209-3319
US

IV. Provider business mailing address

PO BOX 1792
HIGLEY AZ
85236-1792
US

V. Phone/Fax

Practice location:
  • Phone: 480-771-7546
  • Fax:
Mailing address:
  • Phone: 480-771-7546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0116028208
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number5101022765
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number7861
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: