Healthcare Provider Details

I. General information

NPI: 1801813571
Provider Name (Legal Business Name): AILEEN L LUZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 11/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 BROADWAY N
FARGO ND
58102-6704
US

IV. Provider business mailing address

2601 BROADWAY N
FARGO ND
58102-6704
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-2900
  • Fax: 701-234-2996
Mailing address:
  • Phone: 701-234-2900
  • Fax: 701-234-2996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number41674
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9203
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: