Provider Demographics
NPI:1558442335
Name:LUTY, JEFFREY A (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:A
Last Name:LUTY
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 1:17710 SW VINCENT ST
Mailing Address - Street 2:
Mailing Address - City:ALOHA
Mailing Address - State:OR
Mailing Address - Zip Code:97078-1782
Mailing Address - Country:US
Mailing Address - Phone:503-314-4059
Mailing Address - Fax:
Practice Address - Street 1:230 ROWE RD
Practice Address - Street 2:
Practice Address - City:WHEELER
Practice Address - State:OR
Practice Address - Zip Code:97147-0035
Practice Address - Country:US
Practice Address - Phone:503-368-5182
Practice Address - Fax:503-368-5590
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD155853208D00000X
WAMD000473485207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORG26289Medicare UPIN