Provider Demographics
NPI:1528051422
Name:LUTAN, ROBERT G (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:G
Last Name:LUTAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:11125 DUNN RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6132
Mailing Address - Country:US
Mailing Address - Phone:314-839-5522
Mailing Address - Fax:314-839-5351
Practice Address - Street 1:11125 DUNN RD
Practice Address - Street 2:SUITE 204
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6132
Practice Address - Country:US
Practice Address - Phone:314-839-5522
Practice Address - Fax:314-839-5351
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036085097207RC0000X
MO101315207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360850972Medicaid
060065494OtherMORRMCR
IL060065495OtherILRRMCR
177033OtherHLNK
2500837OtherUHC
4243966OtherAETNA
5386951007OtherCIGNA
12857V3831OtherGHP/CMR
MO205722705Medicaid
34842V8816OtherHCUSA
F04428OtherMERCY
MO149885OtherMOBS/BLCHOICE
98151V30946OtherHLTHPART
F04428OtherMERCY
98151V30946OtherHLTHPART
5386951007OtherCIGNA
MO009010900Medicare PIN
34842V8816OtherHCUSA
2500837OtherUHC
12857V3831OtherGHP/CMR