=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215903075
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT FRANK LUTZ III MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2006
-----------------------------------------------------
Last Update Date | 07/23/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1545 E SOUTHLAKE BLVD
-----------------------------------------------------
City | SOUTHLAKE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76092-6422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-557-8205
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P O BOX 960046
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73196-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-485-4474
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | J4314
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------