Basic Information
| Provider Information | |||||||||
| NPI: | 1538289210 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUKE | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 BROOK AVE | ||||||||
| Address2: | |||||||||
| City: | WICHITA FALLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 763015007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9405529901 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 BROOK AVE | ||||||||
| Address2: | |||||||||
| City: | WICHITA FALLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 763015007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9403973143 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 07/11/2013 | ||||||||
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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 | 2084P0800X | F9759 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 127791505 | 05 | TX | MEDICAID |