Provider Demographics
NPI:1518469758
Name:LUTZ, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:LUTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:BURTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:99 SHOREHAM RD
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-7358
Mailing Address - Country:US
Mailing Address - Phone:516-860-6659
Mailing Address - Fax:
Practice Address - Street 1:4644 MERRICK RD
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-6030
Practice Address - Country:US
Practice Address - Phone:516-860-6659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-04
Last Update Date:2018-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007789156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician