Healthcare Provider Details

I. General information

NPI: 1275539645
Provider Name (Legal Business Name): PHILIP LUTZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BAY AVE
MONTCLAIR NJ
07042-4837
US

IV. Provider business mailing address

PO BOX 35088
NEWARK NJ
07193-5088
US

V. Phone/Fax

Practice location:
  • Phone: 800-720-1664
  • Fax:
Mailing address:
  • Phone: 800-720-1664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMA50393
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberME142797
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMA50393
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: