Provider Demographics
NPI:1144395211
Name:GOTTS, LAWRENCE J (DO)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:J
Last Name:GOTTS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1621 S NASHVILLE ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42276-8871
Mailing Address - Country:US
Mailing Address - Phone:270-726-4444
Mailing Address - Fax:270-726-4400
Practice Address - Street 1:1621 S NASHVILLE ST
Practice Address - Street 2:SUITE 104
Practice Address - City:RUSSELLVILLE
Practice Address - State:KY
Practice Address - Zip Code:42276-8871
Practice Address - Country:US
Practice Address - Phone:270-726-4444
Practice Address - Fax:270-726-4400
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY02661207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY080160808OtherMEDICARE RAILROAD
KY64010895Medicaid
KY000000176043OtherBLUE CROSS BLUE SHIELD
KY1837202OtherMEDICARE GROUP NUMBER
KY000000176043OtherBLUE CROSS BLUE SHIELD