Basic Information
| Provider Information | |||||||||
| NPI: | 1376678128 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUKOWIAK | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4027 S 1330 E | ||||||||
| Address2: | |||||||||
| City: | GREENTOWN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469369774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656287018 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2146 E MARKLAND AVE | ||||||||
| Address2: | |||||||||
| City: | KOKOMO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469016240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654549748 | ||||||||
| FaxNumber: | 7654549759 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05006820A | IN | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251P0200X | 05006820A | IN | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000000375492 | 01 | IN | ANTHEM | OTHER |