Healthcare Provider Details

I. General information

NPI: 1104842335
Provider Name (Legal Business Name): MARY K LUECKENHOFF OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY K MIGNECO OD

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 11/11/2022
Certification Date: 11/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BARNES JEWISH HOSPITAL PLZ DIV OPTOMETRY, 1ST FL
SAINT LOUIS MO
63110-1003
US

IV. Provider business mailing address

660 S EUCLID AVE CB 8096
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-6123
  • Fax: 314-747-3726
Mailing address:
  • Phone: 314-362-3937
  • Fax: 314-747-9478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT02959
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: