MEDICARE: DR. JONATHAN P LUDLOW OD

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	TUV0061121	NY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	52833A	OTHER	NY	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	G0185822450	OTHER	NY	BNY
3	TUV006112	OTHER	NY	NEW YORK STATE
4	410043899	OTHER	NY	RRMCR

General Provider Information

NPI Number	:	1417939604
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN P LUDLOW OD

Provider Business Mailing Address
First Line	:	10730A ENDURING FREEDOM DR
Second Line	:
City	:	FORT DRUM
State	:	NY
Zip	:	13602-5405
Country	:	US
Telephone Number	:	315-405-8671
Fax Number	:	315-971-4633

Provider Business Practice Location Address
First Line	:	10730A ENDURING FREEDOM DR STE A
Second Line	:
City	:	FORT DRUM
State	:	NY
Zip	:	13602-5405
Country	:	US
Telephone Number	:	315-405-8671
Fax Number	:	315-773-1820

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

Provider Enumeration Date	:	11/15/2005
Last Update Date	:	11/29/2023

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