=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386340644
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANNA LUTZ MEDICAL PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2023
-----------------------------------------------------
Last Update Date | 02/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 970 41ST ST STE M1
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11219-1105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-935-3015
-----------------------------------------------------
Fax | 718-438-2295
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2124 E 26TH ST
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11229-4933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-935-3015
-----------------------------------------------------
Fax | 718-438-2295
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ANNA LUTZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 917-935-3015
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------