Provider Demographics
NPI:1750340741
Name:LUTZ, CHARLES M (OD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:M
Last Name:LUTZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:211 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6220
Mailing Address - Country:US
Mailing Address - Phone:636-916-5367
Mailing Address - Fax:800-432-6004
Practice Address - Street 1:1944 ZUMBEHL RD
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-2721
Practice Address - Country:US
Practice Address - Phone:636-916-5367
Practice Address - Fax:800-432-6004
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03108152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO314895210Medicaid
44325OtherDAVIS VISION
MOP00403026OtherRR MEDICARE
108615OtherBLUE CROSS BLUE SHIELD MO
20990OtherOPTICARE MED. COMPLETE
UNKNOWNOtherGROUP HEALTH PLAN
MO20264OtherHEALTHCARE USA
108615OtherBLUE CHOICE
22-01201OtherUNITED HEALTHCARE
IL410048087OtherRR MEDICARE
U90217OtherMERCY HEALTH PLANS
110972OtherEYEMED
MO314895202Medicaid
675482OtherHEALTHLINK
108615OtherBLUE CHOICE
44325OtherDAVIS VISION
MO000091367Medicare PIN