Provider Demographics
NPI:1376518704
Name:LUETHKE, RONALD WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:WILLIAM
Last Name:LUETHKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:527 MEDICAL PARK DR STE 400
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9010
Mailing Address - Country:US
Mailing Address - Phone:681-342-3190
Mailing Address - Fax:681-342-3195
Practice Address - Street 1:527 MEDICAL PARK DR STE 203
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9009
Practice Address - Country:US
Practice Address - Phone:681-342-3190
Practice Address - Fax:681-342-3195
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD36862208200000X, 2086S0122X
WV257552086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD531561100Medicaid
MDE28711Medicare UPIN