Provider Demographics
NPI:1659428852
Name:LUTZ, TRAVIS B (M D)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:B
Last Name:LUTZ
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 NICHOLASVILLE RD APT 804
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1484
Mailing Address - Country:US
Mailing Address - Phone:513-515-1100
Mailing Address - Fax:
Practice Address - Street 1:1725 HARRODSBURG RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3601
Practice Address - Country:US
Practice Address - Phone:859-278-7226
Practice Address - Fax:829-276-1540
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY398412085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100050750Medicaid
KY7100050750Medicaid