Provider Demographics
NPI:1316915481
Name:LUEDKE, MARK S (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:LUEDKE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:9433 BALM RIVERVIEW RD
Mailing Address - Street 2:STUITE 102
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-5120
Mailing Address - Country:US
Mailing Address - Phone:813-671-2020
Mailing Address - Fax:813-677-5549
Practice Address - Street 1:9433 BALM RIVERVIEW RD STE 102
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569-5120
Practice Address - Country:US
Practice Address - Phone:813-671-2020
Practice Address - Fax:813-677-5549
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2762152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620037100Medicaid
FL620037100Medicaid
U53491Medicare UPIN