Provider Demographics
NPI:1063470623
Name:WILCOX, LORI-ANN R (MD)
Entity Type:Individual
Prefix:
First Name:LORI-ANN
Middle Name:R
Last Name:WILCOX
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LORI-ANN
Other - Middle Name:R
Other - Last Name:FREEMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:13943 N 91ST AVE
Mailing Address - Street 2:C-101
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-3687
Mailing Address - Country:US
Mailing Address - Phone:623-760-9449
Mailing Address - Fax:623-974-9351
Practice Address - Street 1:13943 N 91ST AVE
Practice Address - Street 2:C-101
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-3687
Practice Address - Country:US
Practice Address - Phone:623-760-9449
Practice Address - Fax:623-974-9351
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24876207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1726808OtherUNITED HEALTHCARE
AZ188961600OtherDEPT OF LABOR WORK COMP
AZAZ0804410OtherBLUE CROSS BLUE SHIELD
WCKLL05OtherMEDICARE ID
AZ1063470623OtherAHCCCS
AZ070010475OtherRAILROAD MEDICARE
AZ1017047OtherAETNA
AZ1Z3908OtherHEALTH NET
AZ99S007000009OtherMEDISUN
AZ379736Medicaid
AZ1017047OtherAETNA
AZ188961600OtherDEPT OF LABOR WORK COMP