Provider Demographics
NPI:1598719932
Name:LUETKE, NICOLE K (DO)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:K
Last Name:LUETKE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 789967
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-9967
Mailing Address - Country:US
Mailing Address - Phone:484-622-7395
Mailing Address - Fax:484-622-7399
Practice Address - Street 1:721 SKIPPACK PIKE
Practice Address - Street 2:SUITE 3
Practice Address - City:BLUE BELL
Practice Address - State:PA
Practice Address - Zip Code:19422-1700
Practice Address - Country:US
Practice Address - Phone:215-793-0600
Practice Address - Fax:215-793-0759
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012680207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1012761050001Medicaid
PA2402357000OtherIBC - PC/KHPE
PA11555034OtherCAQH ID#
PA2402357000OtherAMERIHEALTH/INTERCOUNTY
PA30025600OtherKEYSTONE MERCY
PA5855528OtherCIGNA HMO/PPO
PA7722728OtherAETNA PPO
PA1735036OtherHIGHMARK BLUE SHIELD
PA1132437OtherAETNA HMO
PA1012761050001Medicaid
PA2402357000OtherAMERIHEALTH/INTERCOUNTY