Healthcare Provider Details

I. General information

NPI: 1417202268
Provider Name (Legal Business Name): BETSY K LUKA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 02/17/2020
Certification Date: 02/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4326 W MONTROSE AVE
CHICAGO IL
60641-2016
US

IV. Provider business mailing address

4326 W MONTROSE AVE
CHICAGO IL
60641-2016
US

V. Phone/Fax

Practice location:
  • Phone: 773-883-9100
  • Fax: 773-883-0005
Mailing address:
  • Phone: 773-883-9100
  • Fax: 773-883-0005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number265725-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number051158
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036136306
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: