Provider Demographics
NPI:1770651044
Name:LUTZ, GREGORY ELMAR (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:ELMAR
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 1:6 HASLET AVE
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08540-4914
Mailing Address - Country:US
Mailing Address - Phone:212-606-1648
Mailing Address - Fax:212-517-7033
Practice Address - Street 1:535 E 70TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4872
Practice Address - Country:US
Practice Address - Phone:212-606-1648
Practice Address - Fax:212-517-7033
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2024-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189336174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYE50674Medicare UPIN