Provider Demographics
NPI:1366648081
Name:NYSTROM, LUKAS M (MD)
Entity type:Individual
Prefix:
First Name:LUKAS
Middle Name:M
Last Name:NYSTROM
Suffix:
Gender:M
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:CLEVELAND CLINIC A40
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195-0001
Mailing Address - Country:US
Mailing Address - Phone:216-445-7164
Mailing Address - Fax:216-445-1638
Practice Address - Street 1:9500 EUCLID AVE # A40
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-3328
Practice Address - Country:US
Practice Address - Phone:216-445-7164
Practice Address - Fax:216-445-1638
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.130861207XX0801X
IL036131887207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma