1558581702 NPI number — LUTZ E VENTZKE MD A MEDICAL CORPORATION

Table of content: (NPI 1558581702)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558581702 NPI number — LUTZ E VENTZKE MD A MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LUTZ E VENTZKE MD A MEDICAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558581702
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
01/30/2008
NPI Reactivation Date:
04/30/2008

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22357 MULHOLLAND DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODLAND HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91364-4934
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-704-7248
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7320 WOODLAKE AVE
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
WEST HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91307-1483
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-348-3230
Provider Business Practice Location Address Fax Number:
818-883-4496
Provider Enumeration Date:
04/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VENTZKE
Authorized Official First Name:
LUTZ
Authorized Official Middle Name:
EBERHARD
Authorized Official Title or Position:
PRESIDENT LUTZ E VENTZKE MD A MEDIC
Authorized Official Telephone Number:
818-704-7248

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  A17887 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: A17887 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00A178870 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05D0714631 . This is a "CLIA NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: WA17887A . This is a "PROVIDER NUMBER" identifier . This identifiers is of the category "OTHER".




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