Healthcare Provider Details

I. General information

NPI: 1891900783
Provider Name (Legal Business Name): JEREMY R. LUEDTKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 LEGACY PLZ W
LA PORTE IN
46350-5296
US

IV. Provider business mailing address

400 LEGACY PLZ W
LA PORTE IN
46350-5296
US

V. Phone/Fax

Practice location:
  • Phone: 219-379-3166
  • Fax: 219-324-9730
Mailing address:
  • Phone: 219-379-3166
  • Fax: 219-324-9730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301087609
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number57033-20
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01079264A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: