Provider Demographics
NPI:1316301807
Name:HULTMAN, LUCAS
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:
Last Name:HULTMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:LUKE
Other - Middle Name:
Other - Last Name:HULTMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 UCLA MEDICAL PLAZA SUITE 460
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095
Practice Address - Country:US
Practice Address - Phone:310-443-8999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
CAE5485213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program