Provider Demographics
NPI:1619191368
Name:FULLENKAMP, LUKE G (OD)
Entity type:Individual
Prefix:DR
First Name:LUKE
Middle Name:G
Last Name:FULLENKAMP
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10156 AMBERWOOD CT
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45241-1031
Mailing Address - Country:US
Mailing Address - Phone:513-779-0685
Mailing Address - Fax:513-741-6433
Practice Address - Street 1:11711 PRINCETON PIKE UNIT 941
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45246-2500
Practice Address - Country:US
Practice Address - Phone:513-671-0933
Practice Address - Fax:513-671-0944
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3451 T444152WC0802X
OH3451T444152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHFU0501774Medicare ID - Type Unspecified