Provider Demographics
NPI:1669477998
Name:LUKETIC, KARL J (MD)
Entity Type:Individual
Prefix:
First Name:KARL
Middle Name:J
Last Name:LUKETIC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3118 STONEGATE DR
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-9423
Mailing Address - Country:US
Mailing Address - Phone:419-450-3337
Mailing Address - Fax:
Practice Address - Street 1:3915 SUNFOREST CT
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4453
Practice Address - Country:US
Practice Address - Phone:419-450-3337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35064065207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
03297OtherPARAMOUNT
000000127263OtherANTHEM
1451754OtherUNITED HEALTHCARE
OH0161435Medicaid
OH180035529OtherRAILROAD MEDICARE
0005908039OtherAETNA
OH0734323Medicare PIN
03297OtherPARAMOUNT