Provider Demographics
NPI:1194881748
Name:SPURLOCK, LUTHER D (MD)
Entity type:Individual
Prefix:DR
First Name:LUTHER
Middle Name:D
Last Name:SPURLOCK
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:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:1100 W 10TH ST
Practice Address - Street 2:SUITE 160
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2937
Practice Address - Country:US
Practice Address - Phone:573-341-3043
Practice Address - Fax:573-341-5208
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO107151207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
10855655OtherCAQH PROVIDER ID
MO207874405Medicaid
MOF16849Medicare UPIN
10855655OtherCAQH PROVIDER ID