Basic Information
Provider Information | |||||||||
NPI: | 1285611038 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LUTZ | ||||||||
FirstName: | STEPHEN | ||||||||
MiddleName: | T | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 330 | ||||||||
Address2: |   | ||||||||
City: | TOLEDO | ||||||||
State: | OH | ||||||||
PostalCode: | 436970330 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6144305712 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 15990 MEDICAL DR S | ||||||||
Address2: |   | ||||||||
City: | FINDLAY | ||||||||
State: | OH | ||||||||
PostalCode: | 458408894 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4194234500 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/22/2005 | ||||||||
LastUpdateDate: | 08/23/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 35079580L | OH | Y |   | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
ID | Type | State | Issuer | Description | 2000690 | 01 | OH | UNITED HEALTHCARE | OTHER | 000000365108 | 01 | OH | ANTHEM BCBS | OTHER | 2386805 | 05 | OH |   | MEDICAID | 5122721 | 01 | OH | AETNA USHC | OTHER |