Provider Demographics
NPI:1902063092
Name:LUTTA, KEVIN CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:CHARLES
Last Name:LUTTA
Suffix:
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:PO BOX 75420
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-5420
Mailing Address - Country:US
Mailing Address - Phone:703-383-6469
Mailing Address - Fax:
Practice Address - Street 1:13350 FRANKLIN FARM ROAD
Practice Address - Street 2:SUITE 220
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20171-4095
Practice Address - Country:US
Practice Address - Phone:703-810-5204
Practice Address - Fax:703-810-5411
Is Sole Proprietor?:No
Enumeration Date:2008-05-17
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01011247618207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
538695Medicare PIN