Healthcare Provider Details

I. General information

NPI: 1184729345
Provider Name (Legal Business Name): RENATA LUKEZIC M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 05/04/2023
Certification Date: 05/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 W MARINE VIEW DR BLDG 2010
EVERETT WA
98207-0001
US

IV. Provider business mailing address

1 BOONE RD
BREMERTON WA
98312-1894
US

V. Phone/Fax

Practice location:
  • Phone: 425-304-4037
  • Fax: 425-304-4101
Mailing address:
  • Phone: 360-475-4216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036097174
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number61404191
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: