Provider Demographics
NPI:1114409133
Name:LITTLE LANTERN CLINIC LLC
Entity type:Organization
Organization Name:LITTLE LANTERN CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BIJU
Authorized Official - Middle Name:
Authorized Official - Last Name:LUKOSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:469-788-8545
Mailing Address - Street 1:4541 N JOSEY LN STE 110C
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-4622
Mailing Address - Country:US
Mailing Address - Phone:469-788-8588
Mailing Address - Fax:469-788-7800
Practice Address - Street 1:4541 N JOSEY LN STE 110
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-4622
Practice Address - Country:US
Practice Address - Phone:469-788-8588
Practice Address - Fax:469-788-7800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-06
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 207RG0100X, 208600000X
TXM7387208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty