Provider Demographics
NPI:1801865316
Name:LUTTER, KENNETH STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:STEPHEN
Last Name:LUTTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2200 NORTH MAYFAIR ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2252
Mailing Address - Country:US
Mailing Address - Phone:414-258-9511
Mailing Address - Fax:414-607-3948
Practice Address - Street 1:941 CHATHAM LANE
Practice Address - Street 2:SUITE 215
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-2416
Practice Address - Country:US
Practice Address - Phone:614-457-5191
Practice Address - Fax:614-459-6874
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-05-43082086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0797688Medicaid
OHLU0692482Medicare PIN
OH0692482Medicare PIN
OH0797688Medicaid