Provider Demographics
NPI:1063831535
Name:DR. LUKE FULLENKAMP OPTOMETRIST
Entity Type:Organization
Organization Name:DR. LUKE FULLENKAMP OPTOMETRIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLENKAMP
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:513-284-4562
Mailing Address - Street 1:11711 PRINCETON PIKE
Mailing Address - Street 2:STE 941
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-2534
Mailing Address - Country:US
Mailing Address - Phone:513-671-0933
Mailing Address - Fax:513-671-0944
Practice Address - Street 1:11711 PRINCETON PIKE
Practice Address - Street 2:STE 941
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45246-2534
Practice Address - Country:US
Practice Address - Phone:513-671-0933
Practice Address - Fax:513-671-0944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-14
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3451/T444152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0426113Medicaid
T47355Medicare UPIN
OH0933Medicare PIN