Healthcare Provider Details

I. General information

NPI: 1497955132
Provider Name (Legal Business Name): JESUS LUA, MD, A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2007
Last Update Date: 12/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 E 7TH ST SUITE A
UPLAND CA
91786-6701
US

IV. Provider business mailing address

360 E 7TH ST SUITE A
UPLAND CA
91786-6701
US

V. Phone/Fax

Practice location:
  • Phone: 909-985-5784
  • Fax: 909-985-7844
Mailing address:
  • Phone: 909-985-5784
  • Fax: 909-985-7844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA50698
License Number StateCA

VIII. Authorized Official

Name: JESUS LUA
Title or Position: PHYSICIAN/OWNER
Credential: M.D.
Phone: 909-985-5784