Provider Demographics
NPI:1679955041
Name:KILLPACK, LUKE D (DO)
Entity type:Individual
Prefix:
First Name:LUKE
Middle Name:D
Last Name:KILLPACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5333 MCAULEY DR RM 5003
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1020
Mailing Address - Country:US
Mailing Address - Phone:480-570-4613
Mailing Address - Fax:
Practice Address - Street 1:5333 MCAULEY DR RM 5003
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1020
Practice Address - Country:US
Practice Address - Phone:734-712-3376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-22
Last Update Date:2018-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116028208390200000X
MI5101022765207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program