MEDICARE: DR. MARK EDWARD LUKIN PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	455	NE

General Provider Information

NPI Number	:	1609487180
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK EDWARD LUKIN PH.D.

Provider Business Mailing Address
First Line	:	2744 STRATFORD AVE
Second Line	:
City	:	LINCOLN
State	:	NE
Zip	:	68502-4247
Country	:	US
Telephone Number	:	402-525-9973
Fax Number	:	402-472-6977

Provider Business Practice Location Address
First Line	:	2744 STRATFORD AVE
Second Line	:
City	:	LINCOLN
State	:	NE
Zip	:	68502-4247
Country	:	US
Telephone Number	:	402-525-9973
Fax Number	:	402-472-6977

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2020
Last Update Date	:	08/10/2020

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