MEDICARE: DR. DOUGLAS E LUBEROFF MD

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	208000000X	Pediatrics Physician	9453	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700840030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOUGLAS E LUBEROFF MD

Provider Business Mailing Address
First Line	:	470 HULON LN
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29169-4841
Country	:	US
Telephone Number	:	803-808-0523
Fax Number	:	803-794-6503

Provider Business Practice Location Address
First Line	:	3240 SUNSET BLVD
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29169-3428
Country	:	US
Telephone Number	:	803-808-0523
Fax Number	:	803-794-6503

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

Provider Enumeration Date	:	04/13/2006
Last Update Date	:	03/06/2019

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