Healthcare Provider Details

I. General information

NPI: 1477547990
Provider Name (Legal Business Name): HEATHER MARIE LUTZ DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 11/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 W WALL ST
FROSTPROOF FL
33843-2043
US

IV. Provider business mailing address

950 COUNTY ROAD 17A W
AVON PARK FL
33825-2164
US

V. Phone/Fax

Practice location:
  • Phone: 963-635-4891
  • Fax: 963-635-3545
Mailing address:
  • Phone: 863-452-3000
  • Fax: 963-452-3069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS8816
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: