Provider Demographics
NPI:1417939604
Name:LUDLOW, JONATHAN P (OD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:P
Last Name:LUDLOW
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 1:10730A ENDURING FREEDOM DR
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-5405
Mailing Address - Country:US
Mailing Address - Phone:315-405-8671
Mailing Address - Fax:315-971-4633
Practice Address - Street 1:10730A ENDURING FREEDOM DR STE A
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5405
Practice Address - Country:US
Practice Address - Phone:315-405-8671
Practice Address - Fax:315-773-1820
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV0061121152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02008780Medicaid
NYG0185822450OtherBNY
NYTUV006112OtherNEW YORK STATE
NY410043899OtherRRMCR
NY52833AOtherMEDICARE PTAN
NYDD0369Medicare ID - Type Unspecified