Provider Demographics
NPI:1538175187
Name:LUBER, JACK E (DPM)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:E
Last Name:LUBER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 ISLAND WAY
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-6043
Mailing Address - Country:US
Mailing Address - Phone:781-933-3734
Mailing Address - Fax:
Practice Address - Street 1:425 SALEM ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3337
Practice Address - Country:US
Practice Address - Phone:781-933-3734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPD1514213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY70615OtherBLUE CROSS BLUE SHIELD
MA0334189Medicaid
MA795450OtherTUFTS HEALTH CARE
MA0334189Medicaid
MAY70615OtherBLUE CROSS BLUE SHIELD