Provider Demographics
NPI:1356344337
Name:LUTZ, JOHN L (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:LUTZ
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 1:1234 E. DUPONT RD.
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-9728
Mailing Address - Fax:260-458-5664
Practice Address - Street 1:401 N. SAWYER RD.
Practice Address - Street 2:SUITE B
Practice Address - City:KENDALLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46755-2568
Practice Address - Country:US
Practice Address - Phone:260-347-8430
Practice Address - Fax:260-347-8435
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN02002752A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2004844950Medicaid
IN7450536OtherAETNA
IN000000505165OtherANTHEM
IN9472582OtherCIGNA
INP00436998OtherRAILROAD MEDICARE
IN200484950AMedicaid
IN351972384-038OtherTRICARE
IN7450536OtherAETNA
IND15778Medicare UPIN
INP00436998OtherRAILROAD MEDICARE