Provider Demographics
NPI:1881089787
Name:LAUTZENHEISER, AMBER (DO)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:LAUTZENHEISER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 N LAKE SHORE DR
Mailing Address - Street 2:APT 3304
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-5300
Mailing Address - Country:US
Mailing Address - Phone:813-382-4986
Mailing Address - Fax:
Practice Address - Street 1:1100 MERCER AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IN
Practice Address - Zip Code:46733
Practice Address - Country:US
Practice Address - Phone:260-724-2145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02005395A207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program