1518915305 NPI number — DAVID J LOZANO MD

Table of content: DAVID J LOZANO MD (NPI 1518915305)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518915305 NPI number — DAVID J LOZANO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOZANO
Provider First Name:
DAVID
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518915305
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
126 CLINIC DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOTHAN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36303-1980
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-793-1881
Provider Business Mailing Address Fax Number:
334-340-5918

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5565 MONTGOMERY HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOTHAN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36303-1552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-793-1881
Provider Business Practice Location Address Fax Number:
334-340-5918
Provider Enumeration Date:
05/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  MD.24011 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0214X , with the licence number: MD.24011 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 009961870 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1518915305 . This is a "TRICARE SOUTH" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 7690295 . This is a "AETNA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 515-33484 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 515-48612 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 023023000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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