Healthcare Provider Details

I. General information

NPI: 1134396682
Provider Name (Legal Business Name): PAUL LUKIANOVICH VMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 WEST MAIN STREET
MARLTON NJ
08053
US

IV. Provider business mailing address

9 WEST MAIN STREET
MARLTON NJ
08053
US

V. Phone/Fax

Practice location:
  • Phone: 856-983-5350
  • Fax: 856-983-8440
Mailing address:
  • Phone: 856-983-5350
  • Fax: 856-983-8440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174M00000X
TaxonomyVeterinarian
License Number29V100242700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: