Provider Demographics
NPI:1477547990
Name:LUTZ, HEATHER MARIE (DO)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIE
Last Name:LUTZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 COUNTY ROAD 17A W
Mailing Address - Street 2:
Mailing Address - City:AVON PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33825-2164
Mailing Address - Country:US
Mailing Address - Phone:863-452-3000
Mailing Address - Fax:963-452-3069
Practice Address - Street 1:109 W WALL ST
Practice Address - Street 2:
Practice Address - City:FROSTPROOF
Practice Address - State:FL
Practice Address - Zip Code:33843-2043
Practice Address - Country:US
Practice Address - Phone:963-635-4891
Practice Address - Fax:963-635-3545
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8816207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270137500Medicaid
FLOS8816OtherSTATE LICENSE
FLOS8816OtherSTATE LICENSE
I17049Medicare UPIN