Basic Information
| Provider Information | |||||||||
| NPI: | 1992812002 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TROTTER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TROTTER | ||||||||
| OtherFirstName: | JOHN | ||||||||
| OtherMiddleName: | LOUIS | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 422 HAMILTON BLVD | ||||||||
| Address2: | |||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245925200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345724074 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 422 HAMILTON BLVD | ||||||||
| Address2: | |||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245925200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345724074 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 07/12/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 29684 | WI | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 0101274909 | VA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 31440900 | 05 | WI | MEDICAID | BT1499842 | 01 | DEA NUMBER | OTHER |