Provider Demographics
NPI:1174575096
Name:LUKE, CRYSTAL J (MD)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:J
Last Name:LUKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7135 SYLVANIA AVE
Mailing Address - Street 2:STE 1C
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-5510
Mailing Address - Country:US
Mailing Address - Phone:419-885-8822
Mailing Address - Fax:419-885-9221
Practice Address - Street 1:7135 SYLVANIA AVE
Practice Address - Street 2:STE 1C
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-5510
Practice Address - Country:US
Practice Address - Phone:419-885-8822
Practice Address - Fax:419-885-9221
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35073536207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2290257Medicaid
OHH09831Medicare UPIN
OHLU0897572Medicare ID - Type Unspecified