Basic Information
| Provider Information | |||||||||
| NPI: | 1780872994 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOTT | ||||||||
| FirstName: | FEYISETAN | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3407 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | COFFEYVILLE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 673372138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054744906 | ||||||||
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| Practice Location | |||||||||
| Address1: | 801 W 8TH ST | ||||||||
| Address2: | |||||||||
| City: | COFFEYVILLE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 673374109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202517500 | ||||||||
| FaxNumber: | 6202521715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2007 | ||||||||
| LastUpdateDate: | 11/07/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | P7664 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200687530A | 05 | KS | MEDICAID | FL0518514 | 01 | DEA | OTHER |