Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111NN0400X | Neurology | 13069 | TX |
Y | 111NN0400X | Neurology | CHIR009501 | GA |
NPI | 1366890915 |
---|---|
Provider Name | Jerome Lubbe |
First Address | Marietta, GA 30067-8479 |
Second Address | Marietta, GA 30067-8479 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/05/2016 |
Last Update Date | 24/05/2016 |