Provider Demographics
NPI:1891900783
Name:LUEDTKE, JEREMY R (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:R
Last Name:LUEDTKE
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 1:400 LEGACY PLZ W
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-5296
Mailing Address - Country:US
Mailing Address - Phone:219-379-3166
Mailing Address - Fax:219-324-9730
Practice Address - Street 1:400 LEGACY PLZ W
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-5296
Practice Address - Country:US
Practice Address - Phone:219-379-3166
Practice Address - Fax:219-324-9730
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301087609208600000X
WI57033-20208600000X
IN01079264A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI07028OtherMEDICARE #
IN300008363Medicaid
ININ2920085OtherMEDICARE PTAN