Provider Demographics
NPI:1891727160
Name:LUTTRELL, JOHN MATTHEW
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MATTHEW
Last Name:LUTTRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:
Other - Last Name:LUTTRELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 912215
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-2215
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:1024 S LEMAY AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3929
Practice Address - Country:US
Practice Address - Phone:303-306-7783
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO37751174400000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY116707300Medicaid
CO930079482OtherRAILROAD MEDICARE
CO38357739Medicaid
WY116707300Medicaid
COC335528Medicare PIN