=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700881984
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVOR A LUKETIC MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2005
-----------------------------------------------------
Last Update Date | 12/30/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 701 PRINCETON AVENUE
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-783-3700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2000 A SOUTHBRIDGE PARKWAY STE 300
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-871-4274
-----------------------------------------------------
Fax | 205-871-4301
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 11224
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------