Provider Demographics
NPI:1891488664
Name:LUTZ, BRADLEY BENTON (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:BENTON
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 1:919 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6853
Mailing Address - Country:US
Mailing Address - Phone:307-262-7221
Mailing Address - Fax:
Practice Address - Street 1:725 HAMLINE ST
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58203-2819
Practice Address - Country:US
Practice Address - Phone:701-780-6810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program