Provider Demographics
NPI:1033645296
Name:LURTSEMA, RYAN DANIEL (MD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:DANIEL
Last Name:LURTSEMA
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 1:3601 4TH STREET MAIL STOP 9901
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79430-0002
Mailing Address - Country:US
Mailing Address - Phone:806-743-2757
Mailing Address - Fax:806-743-1180
Practice Address - Street 1:1501 NE MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6051
Practice Address - Country:US
Practice Address - Phone:541-382-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-10
Last Update Date:2024-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD218786207Q00000X
TXR8935207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500837289Medicaid