Healthcare Provider Details

I. General information

NPI: 1649481227
Provider Name (Legal Business Name): TRACIE ELIZABETH LUTHER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 05/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19910 MALVERN RD #222
SHAKER HEIGHTS OH
44122-2823
US

IV. Provider business mailing address

19910 MALVERN RD #222
SHAKER HEIGHTS OH
44122-2823
US

V. Phone/Fax

Practice location:
  • Phone: 917-841-9750
  • Fax:
Mailing address:
  • Phone: 917-841-9750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number229540
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35.126499
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: