Provider Demographics
NPI:1386648343
Name:LUTZ, LARRY W (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:W
Last Name:LUTZ
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 1510
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47706-1510
Mailing Address - Country:US
Mailing Address - Phone:812-753-3942
Mailing Address - Fax:812-768-6283
Practice Address - Street 1:802 E OAK ST
Practice Address - Street 2:
Practice Address - City:FORT BRANCH
Practice Address - State:IN
Practice Address - Zip Code:47648-1666
Practice Address - Country:US
Practice Address - Phone:812-753-3942
Practice Address - Fax:812-768-6283
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027538A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000109173OtherBCBS PIN
IN100356750Medicaid
IN282030Medicare ID - Type Unspecified
IN000000109173OtherBCBS PIN
INC25855Medicare UPIN