Basic Information
| Provider Information | |||||||||
| NPI: | 1356344337 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUTZ | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 E. DUPONT RD. | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739728 | ||||||||
| FaxNumber: | 2604585664 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 N. SAWYER RD. | ||||||||
| Address2: | SUITE B | ||||||||
| City: | KENDALLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467552568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603478430 | ||||||||
| FaxNumber: | 2603478435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 09/29/2009 | ||||||||
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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 | 207X00000X | 02002752A | IN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2004844950 | 05 | IN | MEDICAID | 7450536 | 01 | IN | AETNA | OTHER | 000000505165 | 01 | IN | ANTHEM | OTHER | 9472582 | 01 | IN | CIGNA | OTHER | P00436998 | 01 | IN | RAILROAD MEDICARE | OTHER | 200484950A | 05 | IN | MEDICAID | 351972384-038 | 01 | IN | TRICARE | OTHER |