Provider Demographics
NPI:1366437261
Name:LUTZKE, WAYNE H
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:H
Last Name:LUTZKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4580 STEPHENS CIR NW STE 202
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-3645
Mailing Address - Country:US
Mailing Address - Phone:330-754-4431
Mailing Address - Fax:330-244-8839
Practice Address - Street 1:4580 STEPHENS CIR NW STE 202
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-3645
Practice Address - Country:US
Practice Address - Phone:330-754-4431
Practice Address - Fax:330-244-8839
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.001474208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0091332Medicaid
OHLU0013793Medicare ID - Type Unspecified
OH0091332Medicaid