Provider Demographics
NPI:1306209796
Name:LUTTRELL, JOHN THOMAS
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:THOMAS
Last Name:LUTTRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 WILSHIRE BLVD STE 600
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-2814
Mailing Address - Country:US
Mailing Address - Phone:323-361-3550
Mailing Address - Fax:323-361-8052
Practice Address - Street 1:4650 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027
Practice Address - Country:US
Practice Address - Phone:888-631-2452
Practice Address - Fax:323-361-8988
Is Sole Proprietor?:No
Enumeration Date:2016-04-01
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA154344208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics