Basic Information
| Provider Information | |||||||||
| NPI: | 1336200823 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOUTZENHEISER | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | DANIEL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 990 SYLVAN WAY | ||||||||
| Address2: | |||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983102851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604793657 | ||||||||
| FaxNumber: | 3603737616 | ||||||||
| Practice Location | |||||||||
| Address1: | 990 SYLVAN WAY | ||||||||
| Address2: | |||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983102851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604793657 | ||||||||
| FaxNumber: | 3603737616 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 01/21/2009 | ||||||||
| 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 | 207L00000X | MD00042662 | WA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 0174829 | 01 | WA | LABOR AND INDUSTRIES | OTHER | 911577098-15 | 01 | WA | KITSAP PHYSICIANS SERVICE | OTHER | 8372112 | 05 | WA | MEDICAID | 013194010 | 01 | WA | GROUP HEALTH COOPERATIVE | OTHER | 192575000 | 01 | WA | OWCP | OTHER | LO7098 | 01 | WA | REGENCE | OTHER | 911577098 | 01 | WA | UNIFORM MEDICAL PLAN | OTHER | 911577098 | 01 | WA | PREMERA BLUE CROSS | OTHER |