Healthcare Provider Details

I. General information

NPI: 1063862969
Provider Name (Legal Business Name): PHILLIP MARK LUECKENHOFF O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 06/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2533 WOODSON RD
OVERLAND MO
63114-5436
US

IV. Provider business mailing address

2533 WOODSON RD
OVERLAND MO
63114-5436
US

V. Phone/Fax

Practice location:
  • Phone: 314-423-3874
  • Fax:
Mailing address:
  • Phone: 314-423-3874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2016020853
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: