Provider Demographics
NPI:1801898119
Name:LUTY, JEFFREY L (OD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:L
Last Name:LUTY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N BROWN ST STE A
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:KS
Mailing Address - Zip Code:67410-1824
Mailing Address - Country:US
Mailing Address - Phone:785-263-3651
Mailing Address - Fax:785-263-3561
Practice Address - Street 1:1000 N BROWN ST STE A
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:KS
Practice Address - Zip Code:67410-1824
Practice Address - Country:US
Practice Address - Phone:785-263-3651
Practice Address - Fax:785-263-3561
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1404152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100220010BMedicaid
KS4189160001Medicare NSC
KS650851Medicare PIN
KSU46093Medicare UPIN