Provider Demographics
NPI:1053963991
Name:LUO, DI (PT)
Entity type:Individual
Prefix:
First Name:DI
Middle Name:
Last Name:LUO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 ROCKY RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-1521
Mailing Address - Country:US
Mailing Address - Phone:678-431-0628
Mailing Address - Fax:
Practice Address - Street 1:8509 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-2414
Practice Address - Country:US
Practice Address - Phone:678-431-0628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT014099225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPT014099OtherGEORGIA STATE BOARD OF PHYSICAL THERAPY