Healthcare Provider Details

I. General information

NPI: 1255628020
Provider Name (Legal Business Name): JOHN STEPHEN LUTZ JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2011
Last Update Date: 01/09/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 E FORTIFICATION ST
JACKSON MS
39202-2442
US

IV. Provider business mailing address

1026 N FLOWOOD DR
JACKSON MS
39232-9532
US

V. Phone/Fax

Practice location:
  • Phone: 601-354-4488
  • Fax:
Mailing address:
  • Phone: 844-824-6605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number23833
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number23833
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: