Provider Demographics
NPI:1477506582
Name:LUTZ, CHARLES J (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:LUTZ
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:104 UNION AVE
Mailing Address - Street 2:SUITE 1001-1002
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-1843
Mailing Address - Country:US
Mailing Address - Phone:315-423-7192
Mailing Address - Fax:315-423-8013
Practice Address - Street 1:104 UNION AVE
Practice Address - Street 2:SUITE 1001-1002
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1843
Practice Address - Country:US
Practice Address - Phone:315-423-7192
Practice Address - Fax:315-423-8013
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2016-02-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY223983208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02298608Medicaid
H74251Medicare UPIN
NYDD3384Medicare PIN
NYCC4406Medicare PIN