Provider Demographics
NPI:1992776108
Name:LUA, JESUS (MD)
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:LUA
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 1:360 E 7TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-6701
Mailing Address - Country:US
Mailing Address - Phone:909-985-5784
Mailing Address - Fax:909-985-7844
Practice Address - Street 1:360 E 7TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-6701
Practice Address - Country:US
Practice Address - Phone:909-985-5784
Practice Address - Fax:909-985-7844
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50698207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A506980Medicaid
CA1497955132Medicaid
CA1497955132Medicaid
CA00A506980Medicaid