Provider Demographics
NPI:1760420889
Name:LAUTZENHEISER, THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:LAUTZENHEISER
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 1:1052 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:VAN WERT
Mailing Address - State:OH
Mailing Address - Zip Code:45891
Mailing Address - Country:US
Mailing Address - Phone:419-238-6747
Mailing Address - Fax:419-238-3721
Practice Address - Street 1:1052 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891
Practice Address - Country:US
Practice Address - Phone:419-238-6747
Practice Address - Fax:419-238-3721
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35042467207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHA78002Medicare UPIN