Provider Demographics
NPI:1265608186
Name:LUTSI, BRANT JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:BRANT
Middle Name:JOSEPH
Last Name:LUTSI
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 1:5328 ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-7203
Mailing Address - Country:US
Mailing Address - Phone:312-339-7290
Mailing Address - Fax:
Practice Address - Street 1:1321 COTTONWOOD ST
Practice Address - Street 2:SUITE 203
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-5131
Practice Address - Country:US
Practice Address - Phone:530-668-2600
Practice Address - Fax:530-662-7330
Is Sole Proprietor?:No
Enumeration Date:2008-04-30
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036113495207RG0100X
CA105415207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHB174ZMedicare PIN