Basic Information
| Provider Information | |||||||||
| NPI: | 1194714741 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUTZ | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1108 HIGHWAY 66 | ||||||||
| Address2: | BOX 1520 | ||||||||
| City: | MORIARTY | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058324434 | ||||||||
| FaxNumber: | 5058325024 | ||||||||
| Practice Location | |||||||||
| Address1: | 1108 HIGHWAY 66 | ||||||||
| Address2: | BOX 1520 | ||||||||
| City: | MORIARTY | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058324434 | ||||||||
| FaxNumber: | 5058325024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2005 | ||||||||
| LastUpdateDate: | 07/28/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20030611 | NM | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 81883552 | 05 | NM | MEDICAID |