=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992012728
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IGNACIO H LUNA MD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2010
-----------------------------------------------------
Last Update Date | 10/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 426 EIGHTH ST. SUITE 300
-----------------------------------------------------
City | GLEN DALE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-845-6400
-----------------------------------------------------
Fax | 304-845-3852
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 426 EIGHTH ST. SUITE 300
-----------------------------------------------------
City | GLEN DALE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-845-6400
-----------------------------------------------------
Fax | 304-845-3852
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | IGNACIO HOELZL LUNA JR.
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 304-845-6400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | 35.100261
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | 10356
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------