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General NPI Number Information
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NPI Number | 1548903040
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Entity Type | Individual
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Provider Name | JOHNATHAN MARK LUTH DO
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Gender | Male
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Dates
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Enumeration Date | 04/14/2022
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Last Update Date | 03/12/2024
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Provider Practice Location Address
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Address Line | 964 AJAX STREET
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City | JACKSONVILLE
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State | FL
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Zip | 32212
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Country | US
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Telephone | 904-546-7094
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Fax |
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Provider Business Mailing Address
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Address Line | 8901 WISCONSIN AVE
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City | BETHESDA
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State | MD
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Zip | 20889-0004
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 0102208035
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License Number State | VA
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