Provider Demographics
NPI:1437115235
Name:LUTZ, MELINDA ANN (OD)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:ANN
Last Name:LUTZ
Suffix:
Gender:F
Credentials:OD
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 1809
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-1809
Mailing Address - Country:US
Mailing Address - Phone:970-264-4300
Mailing Address - Fax:970-264-4400
Practice Address - Street 1:286 HERMOSA ST
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-1809
Practice Address - Country:US
Practice Address - Phone:970-264-4300
Practice Address - Fax:970-264-4400
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1501152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08015018Medicaid
CO43293Medicare ID - Type Unspecified
COU11177Medicare UPIN