Provider Demographics
NPI:1306952106
Name:LUTHER, STEVAN W (MD)
Entity type:Individual
Prefix:
First Name:STEVAN
Middle Name:W
Last Name:LUTHER
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 450
Mailing Address - Street 2:
Mailing Address - City:SEDRO WOOLLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98284-0450
Mailing Address - Country:US
Mailing Address - Phone:360-855-1411
Mailing Address - Fax:360-855-1933
Practice Address - Street 1:830 BALL ST
Practice Address - Street 2:
Practice Address - City:SEDRO WOOLLEY
Practice Address - State:WA
Practice Address - Zip Code:98284-0450
Practice Address - Country:US
Practice Address - Phone:360-855-1411
Practice Address - Fax:360-855-1933
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00013149207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1001601Medicaid
A09004Medicare UPIN
WAAB17423Medicare ID - Type Unspecified