Basic Information
| Provider Information | |||||||||
| NPI: | 1629294665 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOTT | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 S FISKE BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329554306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043884646 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2606 PARK ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322044520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043884646 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME131370 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics | 2080H0002X | 001265 | GA | N | Allopathic & Osteopathic Physicians | Pediatrics | Hospice and Palliative Medicine | 208000000X | 62137 | GA | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | GRP2665 | 01 | GA | EMPLOYER ID | OTHER | PENDING | 01 | FL | MEDICARE | OTHER | 001265 | 01 | GA | RESIDENCY LICENSE | OTHER | 369518390E | 05 | GA | MEDICAID | 52319773 | 01 | GA | BCBS | OTHER |