1619391836 NPI number — DR LUKE FULLENKAMP

Table of content: DR. WILLIAM WAYNE MUMBY D.D.S. (NPI 1306013164)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619391836 NPI number — DR LUKE FULLENKAMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR LUKE FULLENKAMP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619391836
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11711 PRINCETON PIKE
Provider Second Line Business Mailing Address:
SUITE 941
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45246-2534
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-671-0933
Provider Business Mailing Address Fax Number:
513-671-0944

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11711 PRINCETON PIKE
Provider Second Line Business Practice Location Address:
SUITE 941
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45246-2534
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-671-0933
Provider Business Practice Location Address Fax Number:
513-671-0944
Provider Enumeration Date:
02/07/2014

Additional Information

Authorized Official

Authorized Official Last Name:
FULLENKAMP
Authorized Official First Name:
LUKE
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
513-671-0993

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  3451/T4444 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0426113 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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