Provider Demographics
NPI:1093862005
Name:LUTTRELL, BOBBY GENE (DO)
Entity Type:Individual
Prefix:
First Name:BOBBY
Middle Name:GENE
Last Name:LUTTRELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7740 QUEENSBURY DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-4702
Mailing Address - Country:US
Mailing Address - Phone:865-405-1902
Mailing Address - Fax:
Practice Address - Street 1:5030 KINGSTON PIKE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-5187
Practice Address - Country:US
Practice Address - Phone:865-588-4052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN81465156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4094205OtherBLUE CROSS BLUE SHIELD NU