Provider Demographics
NPI:1104842335
Name:LUECKENHOFF, MARY K (OD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:K
Last Name:LUECKENHOFF
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:K
Other - Last Name:MIGNECO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:CB 8096
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-362-3937
Mailing Address - Fax:314-747-9478
Practice Address - Street 1:1 BARNES JEWISH HOSPITAL PLZ
Practice Address - Street 2:DIV OPTOMETRY, 1ST FL
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1003
Practice Address - Country:US
Practice Address - Phone:314-362-6123
Practice Address - Fax:314-747-3726
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02959152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO313588709Medicaid
ILENROLLEDMedicaid
IL$$$$$$$$$Medicaid
MO046010103Medicaid