Provider Demographics
NPI:1932195021
Name:LUTZ, KEVIN WILLIAM (DPM)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:WILLIAM
Last Name:LUTZ
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 E BROAD ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-3988
Mailing Address - Country:US
Mailing Address - Phone:614-461-6634
Mailing Address - Fax:614-461-7136
Practice Address - Street 1:720 E BROAD ST
Practice Address - Street 2:SUITE 100
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-3988
Practice Address - Country:US
Practice Address - Phone:614-461-6634
Practice Address - Fax:614-461-7136
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003275213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH11108332OtherCAQH
OH2458648Medicaid
OH11108332OtherCAQH
OH4126835Medicare PIN