Provider Demographics
NPI:1477573319
Name:LUTTRULL, JEFFREY K (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:K
Last Name:LUTTRULL
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 1:3160 TELEGRAPH RD.
Mailing Address - Street 2:#230
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-3233
Mailing Address - Country:US
Mailing Address - Phone:805-650-0664
Mailing Address - Fax:
Practice Address - Street 1:3160 TELEGRAPH RD.
Practice Address - Street 2:#230
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-3233
Practice Address - Country:US
Practice Address - Phone:805-650-0664
Practice Address - Fax:805-650-0865
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA770344068207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA770344068OtherCALIFORNIA LICENCE
CAC46632Medicare UPIN
CAG50280Medicare ID - Type Unspecified