Provider Demographics
NPI:1952352221
Name:LUTZ, LON (MD)
Entity Type:Individual
Prefix:
First Name:LON
Middle Name:
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 1:600 S CLIFF AVE
Mailing Address - Street 2:STE 106
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-5355
Mailing Address - Country:US
Mailing Address - Phone:888-258-0894
Mailing Address - Fax:
Practice Address - Street 1:7200 HUDSON BLVD N
Practice Address - Street 2:STE 135
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-7055
Practice Address - Country:US
Practice Address - Phone:651-313-8250
Practice Address - Fax:651-313-8251
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30820208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1952352221Medicaid
MN720000044Medicare PIN
E27249Medicare UPIN