Provider Demographics
NPI:1811994213
Name:LUTZ, DAVID J (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:LUTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7956 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4140
Mailing Address - Country:US
Mailing Address - Phone:260-436-2416
Mailing Address - Fax:260-436-6936
Practice Address - Street 1:7956 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-436-2416
Practice Address - Fax:260-436-6936
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057270A2081P2900X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200423930Medicaid
OH2386323Medicaid
IN250014246OtherRR MEDICARE
MI4835821Medicaid
INP00206255OtherRR MEDICARE
IN5506830003Medicare NSC
IN132000LMedicare PIN
MI4835821Medicaid
H79013Medicare UPIN
OH2386323Medicaid
IN250014246Medicare PIN