Basic Information
| Provider Information | |||||||||
| NPI: | 1366426868 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUJAN | ||||||||
| FirstName: | GIOVANNI | ||||||||
| MiddleName: | MARIO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LUJAN CASTILLO | ||||||||
| OtherFirstName: | MARIO | ||||||||
| OtherMiddleName: | GEOVANNI | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 700 ACKERMAN RD STE 2120 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432021559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142935905 | ||||||||
| FaxNumber: | 6142934715 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 W 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432101240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142935905 | ||||||||
| FaxNumber: | 6142934715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 01/30/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | L8421 | TX | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 5829457-1205 | UT | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 27635 | SC | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | ME94351 | FL | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 056336 | GA | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 36050 | IA | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 24686 | OK | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | MD.200176 | LA | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | D59742 | MD | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 2005-00710 | NC | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 35.086723 | OH | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 8M8258 | 01 | TX | BCBS | OTHER | 0386979 | 05 | OH | MEDICAID |