Provider Demographics
NPI:1740385426
Name:LUTZ, JON E (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:E
Last Name:LUTZ
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 1:1501 NE MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6051
Mailing Address - Country:US
Mailing Address - Phone:541-382-2811
Mailing Address - Fax:
Practice Address - Street 1:1501 NE MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6051
Practice Address - Country:US
Practice Address - Phone:541-382-2811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53950207R00000X, 207RI0200X
ORMD29015207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA770460211Medicaid
OR00834442OtherMEDICARE RAILROAD
OR500605415Medicaid
OR00834442OtherMEDICARE RAILROAD
CA00G53950Medicare ID - Type Unspecified
ORR146764Medicare PIN