Provider Demographics
NPI:1174651632
Name:LUDWIG, GARY (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:LUDWIG
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 1:1101 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-1509
Mailing Address - Country:US
Mailing Address - Phone:269-983-3461
Mailing Address - Fax:
Practice Address - Street 1:1101 MAIN ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-1509
Practice Address - Country:US
Practice Address - Phone:269-983-3461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002918207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOA16535Medicare ID - Type UnspecifiedMEDICARE