Provider Demographics
NPI:1982740775
Name:LUTZ, MICHAEL EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EDWARD
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 1:4465 BAYMEADOWS RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217
Mailing Address - Country:US
Mailing Address - Phone:904-737-0111
Mailing Address - Fax:904-737-4422
Practice Address - Street 1:4465 BAYMEADOWS RD
Practice Address - Street 2:SUITE 5
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217
Practice Address - Country:US
Practice Address - Phone:904-737-0111
Practice Address - Fax:904-737-4422
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME74101207N00000X, 207ND0101X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00137052OtherRAILROAD MEDICARE
42484OtherBCBS
42484XMedicare ID - Type Unspecified
P00137052OtherRAILROAD MEDICARE