Healthcare Provider Details

I. General information

NPI: 1356344337
Provider Name (Legal Business Name): JOHN L LUTZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 09/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N. SAWYER RD. SUITE B
KENDALLVILLE IN
46755-2568
US

IV. Provider business mailing address

1234 E. DUPONT RD. SUITE 3
FORT WAYNE IN
46825-1545
US

V. Phone/Fax

Practice location:
  • Phone: 260-347-8430
  • Fax: 260-347-8435
Mailing address:
  • Phone: 260-373-9728
  • Fax: 260-458-5664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number02002752A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: