Basic Information
| Provider Information | |||||||||
| NPI: | 1750340741 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUTZ | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 211 E BROADWAY | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620026220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6369165367 | ||||||||
| FaxNumber: | 8004326004 | ||||||||
| Practice Location | |||||||||
| Address1: | 1944 ZUMBEHL RD | ||||||||
| Address2: | |||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633032721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6369165367 | ||||||||
| FaxNumber: | 8004326004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2006 | ||||||||
| LastUpdateDate: | 12/19/2012 | ||||||||
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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 | 152W00000X | T03108 | MO | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 314895210 | 05 | MO | MEDICAID | 44325 | 01 | DAVIS VISION | OTHER | P00403026 | 01 | MO | RR MEDICARE | OTHER | 108615 | 01 | BLUE CROSS BLUE SHIELD MO | OTHER | 20990 | 01 | OPTICARE MED. COMPLETE | OTHER | UNKNOWN | 01 | GROUP HEALTH PLAN | OTHER | 20264 | 01 | MO | HEALTHCARE USA | OTHER | 108615 | 01 | BLUE CHOICE | OTHER | 22-01201 | 01 | UNITED HEALTHCARE | OTHER | 410048087 | 01 | IL | RR MEDICARE | OTHER | U90217 | 01 | MERCY HEALTH PLANS | OTHER | 110972 | 01 | EYEMED | OTHER | 314895202 | 05 | MO | MEDICAID | 675482 | 01 | HEALTHLINK | OTHER |