Provider Demographics
NPI:1558581702
Name:LUTZ E VENTZKE MD A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:LUTZ E VENTZKE MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT LUTZ E VENTZKE MD A MEDIC
Authorized Official - Prefix:
Authorized Official - First Name:LUTZ
Authorized Official - Middle Name:EBERHARD
Authorized Official - Last Name:VENTZKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-704-7248
Mailing Address - Street 1:22357 MULHOLLAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-4934
Mailing Address - Country:US
Mailing Address - Phone:818-704-7248
Mailing Address - Fax:
Practice Address - Street 1:7320 WOODLAKE AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91307-1483
Practice Address - Country:US
Practice Address - Phone:818-348-3230
Practice Address - Fax:818-883-4496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-30
Last Update Date:2008-04-30
Deactivation Date:2008-01-30
Deactivation Code:
Reactivation Date:2008-04-30
Provider Licenses
StateLicense IDTaxonomies
CAA17887207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A178870Medicaid
05D0714631OtherCLIA NUMBER
WA17887AOtherPROVIDER NUMBER
CA00A178870Medicaid
A21096Medicare UPIN