Provider Demographics
NPI:1790814481
Name:LUTTRELL, BRADY L (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADY
Middle Name:L
Last Name:LUTTRELL
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:PO BOX 505673
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5673
Mailing Address - Country:US
Mailing Address - Phone:417-730-6430
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:3203 E OLD STONE AVE
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MO
Practice Address - Zip Code:65619-9620
Practice Address - Country:US
Practice Address - Phone:417-269-1910
Practice Address - Fax:417-269-1916
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021047213207Q00000X, 207Q00000X
TXM6733207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX189052701Medicaid
TX189052702Medicaid
TXP00701233Medicare PIN
TX8K0035Medicare PIN
TX189052702Medicaid
TX189052701Medicaid