Provider Demographics
NPI:1477559680
Name:LUTTRELL, REX E (MD)
Entity Type:Individual
Prefix:
First Name:REX
Middle Name:E
Last Name:LUTTRELL
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 5209
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72078-5209
Mailing Address - Country:US
Mailing Address - Phone:501-978-4343
Mailing Address - Fax:501-975-8995
Practice Address - Street 1:1300 BRADEN ST
Practice Address - Street 2:POD B
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-3719
Practice Address - Country:US
Practice Address - Phone:501-978-4343
Practice Address - Fax:501-975-8995
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-6721208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR123268001Medicaid
AR16173000000OtherQUALCHOICE
AR17-20039OtherUNITED HEALTHCARE
P01071366OtherRRMEDICARE
P00004959OtherRAILROAD MEDICARE
AR17-20039OtherUNITED HEALTHCARE
AR5J069Medicare ID - Type Unspecified
F54652Medicare UPIN