Provider Demographics
NPI:1356904627
Name:LUTZ, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:LUTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33133 RANCH RD
Mailing Address - Street 2:
Mailing Address - City:DADE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33523-9164
Mailing Address - Country:US
Mailing Address - Phone:727-278-6205
Mailing Address - Fax:
Practice Address - Street 1:4131 DAY BRIDGE PL
Practice Address - Street 2:
Practice Address - City:ELLENTON
Practice Address - State:FL
Practice Address - Zip Code:34222-7236
Practice Address - Country:US
Practice Address - Phone:727-278-6205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-22
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities