Basic Information
Provider Information | |||||||||
NPI: | 1184707952 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LOTT | ||||||||
FirstName: | VICKY | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 623 SOUTH MAIN STREET | ||||||||
Address2: |   | ||||||||
City: | MOSCOW | ||||||||
State: | ID | ||||||||
PostalCode: | 83843 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2088822011 | ||||||||
FaxNumber: | 2088831853 | ||||||||
Practice Location | |||||||||
Address1: | 623 SOUTH MAIN STREET | ||||||||
Address2: |   | ||||||||
City: | MOSCOW | ||||||||
State: | ID | ||||||||
PostalCode: | 83843 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2088822011 | ||||||||
FaxNumber: | 2088831853 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/23/2006 | ||||||||
LastUpdateDate: | 11/17/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M8278 | ID | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | MD00040077 | WA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1104639 | 01 | ID | DMERC | OTHER | 48264 | 01 | ID | BLUE CROSS | OTHER | 806323500 | 01 | ID | HEATHY CONNECTIONS | OTHER | 000010138246 | 01 | ID | REGENCE BLUESHIELD | OTHER | 806323500 | 05 | ID |   | MEDICAID | 0159575 | 01 | WA | WA LABOR & INDUSTRIES | OTHER | 8298937 | 05 | WA |   | MEDICAID |