Healthcare Provider Details

I. General information

NPI: 1033379649
Provider Name (Legal Business Name): SANJIVA MICHAEL LUTCHMEDIAL MD.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 04/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 MORTON PLANT ST STE 405
CLEARWATER FL
33756
US

IV. Provider business mailing address

2900 LAMB CIRCLE, SUITE 7-700B. CARILION NEW RIVER VALLEY (CMRV)
CHRISTIANSBURG VA
24073
US

V. Phone/Fax

Practice location:
  • Phone: 727-443-0611
  • Fax: 727-461-5493
Mailing address:
  • Phone: 540-731-2000
  • Fax: 540-983-1133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number0101254085
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberME133652
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: