Provider Demographics
NPI:1538316112
Name:LUTZ, JONATHAN M (OD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:M
Last Name:LUTZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:742 MCKNIGHT DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KNIGHTDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27545-7764
Mailing Address - Country:US
Mailing Address - Phone:919-266-2048
Mailing Address - Fax:
Practice Address - Street 1:742 MCKNIGHT DR
Practice Address - Street 2:SUITE 100
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-7764
Practice Address - Country:US
Practice Address - Phone:919-266-2048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-26
Last Update Date:2009-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2118152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2473184Medicare PIN