Provider Demographics
NPI:1164493250
Name:LUTEN, ROBERT CORNELIUS (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:CORNELIUS
Last Name:LUTEN
Suffix:
Gender:M
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:PO BOX 44008
Mailing Address - Street 2:UFJP PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:655 W 8TH ST
Practice Address - Street 2:UFJP EMERGENCY MEDICINE
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-244-7234
Practice Address - Fax:904-244-4508
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME34114207P00000X, 207PP0204X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0399078-00Medicaid
GA000218908AMedicaid
FL930003868OtherRAILROAD MEDICARE
FL930003868OtherRAILROAD MEDICARE
GA000218908AMedicaid
FL15593YMedicare PIN