Provider Demographics
NPI:1013397363
Name:LUTZ, GINA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:LUTZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 N GUADALUPE ST
Mailing Address - Street 2:PMB 210
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1868
Mailing Address - Country:US
Mailing Address - Phone:505-209-5240
Mailing Address - Fax:951-269-4057
Practice Address - Street 1:5600 EUBANK BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-1518
Practice Address - Country:US
Practice Address - Phone:505-872-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-02
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2019-0932207Q00000X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine