Healthcare Provider Details

I. General information

NPI: 1538175187
Provider Name (Legal Business Name): JACK E LUBER DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 SALEM ST
MEDFORD MA
02155-3337
US

IV. Provider business mailing address

8 ISLAND WAY
ANDOVER MA
01810-6043
US

V. Phone/Fax

Practice location:
  • Phone: 781-933-3734
  • Fax:
Mailing address:
  • Phone: 781-933-3734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPD1514
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: