Provider Demographics
NPI:1003084674
Name:JEFFREY K. LUTTRULL, M. D. A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:JEFFREY K. LUTTRULL, M. D. A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:LUTTRULL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-650-0664
Mailing Address - Street 1:3160 TELEGRAPH RD STE 230
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-3252
Mailing Address - Country:US
Mailing Address - Phone:805-650-0664
Mailing Address - Fax:
Practice Address - Street 1:3160 TELEGRAPH RD STE 230
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-3252
Practice Address - Country:US
Practice Address - Phone:805-650-0664
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7015319OtherMEDI-CAL
CAG50280Medicare UPIN