Provider Demographics
NPI:1669574794
Name:LUCKHARDT, SHARON MARY (OD)
Entity type:Individual
Prefix:DR
First Name:SHARON
Middle Name:MARY
Last Name:LUCKHARDT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 N CASS AVE
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-1604
Mailing Address - Country:US
Mailing Address - Phone:630-969-2807
Mailing Address - Fax:
Practice Address - Street 1:136 N CASS AVE
Practice Address - Street 2:
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-1604
Practice Address - Country:US
Practice Address - Phone:630-969-2807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL045006139152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK16174OtherPTAN
IL1669574794OtherNPI
ILK16174Medicare UPIN