Healthcare Provider Details

I. General information

NPI: 1790814481
Provider Name (Legal Business Name): BRADY L LUTTRELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3203 E OLD STONE AVE
BROOKLINE MO
65619-9620
US

IV. Provider business mailing address

PO BOX 505673
SAINT LOUIS MO
63150-5673
US

V. Phone/Fax

Practice location:
  • Phone: 417-269-1910
  • Fax: 417-269-1916
Mailing address:
  • Phone: 417-730-6430
  • Fax: 417-269-7567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2021047213
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: