Provider Demographics
NPI:1063862969
Name:LUECKENHOFF, PHILLIP MARK (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:MARK
Last Name:LUECKENHOFF
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2533 WOODSON RD
Mailing Address - Street 2:
Mailing Address - City:OVERLAND
Mailing Address - State:MO
Mailing Address - Zip Code:63114-5436
Mailing Address - Country:US
Mailing Address - Phone:314-423-3874
Mailing Address - Fax:
Practice Address - Street 1:2533 WOODSON RD
Practice Address - Street 2:
Practice Address - City:OVERLAND
Practice Address - State:MO
Practice Address - Zip Code:63114-5436
Practice Address - Country:US
Practice Address - Phone:314-423-3874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016020853152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist