Provider Demographics
NPI:1710111489
Name:LUTZ, CORDULA DAVIS (MD)
Entity Type:Individual
Prefix:
First Name:CORDULA
Middle Name:DAVIS
Last Name:LUTZ
Suffix:
Gender:F
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5929 SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-4123
Practice Address - Country:US
Practice Address - Phone:704-667-5160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2010-01668208000000X, 208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC157474OtherRESIDENT TRAINING LICENSE
NC2010-01668OtherUNRESTRICTED LICENSE
NC5920354Medicaid
NCAC5385578-R543OtherDEA
SCNC1678Medicaid
NCNC6948GMedicare PIN
NCNC6948BMedicare PIN
NC5920354Medicaid
NCNC6948CMedicare PIN
NCNC6948IMedicare PIN
NC2010-01668OtherUNRESTRICTED LICENSE
NCAC5385578-R543OtherDEA
SCNC1678Medicaid