Basic Information
| Provider Information | |||||||||
| NPI: | 1083931406 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUTSKE | ||||||||
| FirstName: | MARSHALL | ||||||||
| MiddleName: | ELI | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1718 PEACHTREE ST NW STE 360 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303097038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043509505 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1700 MEDICAL WAY | ||||||||
| Address2: | |||||||||
| City: | SNELLVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300782195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709790200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2010 | ||||||||
| LastUpdateDate: | 03/30/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 78378 | GA | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | 78378 | GA | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.