Healthcare Provider Details

I. General information

NPI: 1619191368
Provider Name (Legal Business Name): LUKE G FULLENKAMP O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 12/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11711 PRINCETON PIKE UNIT 941
CINCINNATI OH
45246-2500
US

IV. Provider business mailing address

10156 AMBERWOOD CT
CINCINNATI OH
45241-1031
US

V. Phone/Fax

Practice location:
  • Phone: 513-671-0933
  • Fax: 513-671-0944
Mailing address:
  • Phone: 513-779-0685
  • Fax: 513-741-6433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number3451 T444
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3451T444
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: