Provider Demographics
NPI:1255333845
Name:LUTZ, DANIEL SIMEON (DC)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:SIMEON
Last Name:LUTZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 CIVIC HEIGHTS DR
Mailing Address - Street 2:STE 108
Mailing Address - City:CIRCLE PINES
Mailing Address - State:MN
Mailing Address - Zip Code:55014-4711
Mailing Address - Country:US
Mailing Address - Phone:763-795-8300
Mailing Address - Fax:763-795-8302
Practice Address - Street 1:620 CIVIC HEIGHTS DR
Practice Address - Street 2:STE 108
Practice Address - City:CIRCLE PINES
Practice Address - State:MN
Practice Address - Zip Code:55014-4711
Practice Address - Country:US
Practice Address - Phone:763-795-8300
Practice Address - Fax:763-795-8302
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN003573111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN00B20LUOtherBLUECROSS BLUESHIELD
MN569713100Medicaid
MN1501695OtherFIRST HEALTH
MN350001922Medicare ID - Type Unspecified
MN1501695OtherFIRST HEALTH