Provider Demographics
NPI:1548276223
Name:REX EDWARD LUTTRELL MD PA
Entity type:Organization
Organization Name:REX EDWARD LUTTRELL MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REX
Authorized Official - Middle Name:E
Authorized Official - Last Name:LUTTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-978-4343
Mailing Address - Street 1:PO BOX 5209
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72078-5209
Mailing Address - Country:US
Mailing Address - Phone:501-978-4343
Mailing Address - Fax:501-975-8995
Practice Address - Street 1:1300 BRADEN ST
Practice Address - Street 2:POD B
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-3719
Practice Address - Country:US
Practice Address - Phone:501-978-4343
Practice Address - Fax:501-975-8995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC2274208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR149546002Medicaid
ARF54652Medicare UPIN
AR5C830Medicare ID - Type UnspecifiedCLINIC GROUP NUMBER