Provider Demographics
NPI:1144294034
Name:LUTZ, FREDRICK BROWN III (MD)
Entity type:Individual
Prefix:DR
First Name:FREDRICK
Middle Name:BROWN
Last Name:LUTZ
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1541 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4615
Mailing Address - Country:US
Mailing Address - Phone:850-431-7801
Mailing Address - Fax:850-431-7809
Practice Address - Street 1:1541 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4615
Practice Address - Country:US
Practice Address - Phone:850-431-7801
Practice Address - Fax:850-431-7809
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME58245207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL267032100Medicaid
FL11514WMedicare ID - Type UnspecifiedMEDICARE NUMBER
FL11514VMedicare PIN
FLE66214Medicare UPIN