Provider Demographics
NPI:1548386352
Name:LUTZ, EDWARD W
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:W
Last Name:LUTZ
Suffix:
Gender:M
Credentials:
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 940
Mailing Address - Street 2:
Mailing Address - City:MAHOPAC
Mailing Address - State:NY
Mailing Address - Zip Code:10541-0940
Mailing Address - Country:US
Mailing Address - Phone:845-628-5578
Mailing Address - Fax:845-628-1654
Practice Address - Street 1:880 S LAKE BLVD
Practice Address - Street 2:
Practice Address - City:MAHOPAC
Practice Address - State:NY
Practice Address - Zip Code:10541-4771
Practice Address - Country:US
Practice Address - Phone:845-628-5578
Practice Address - Fax:845-628-1654
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6185225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ59791Medicare PIN