MEDICARE: KELLY MARIE LUDDEN-LIAUW O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	TUV006690	NY
2	152W00000X	Optometrist	27OA00679900	NJ

General Provider Information

NPI Number	:	1124011200
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY MARIE LUDDEN-LIAUW O.D.

Provider Business Mailing Address
First Line	:	70 THE PROMENADE
Second Line	:
City	:	EDGEWATER
State	:	NJ
Zip	:	07020-2127
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	70 THE PROMENADE
Second Line	:
City	:	EDGEWATER
State	:	NJ
Zip	:	07020-2127
Country	:	US
Telephone Number	:	201-945-5487
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2005
Last Update Date	:	10/02/2019

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