Provider Demographics
NPI:1275695108
Name:WITCHER, LORI D (M D)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:D
Last Name:WITCHER
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1709 BRIAR CIR
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-6222
Mailing Address - Country:US
Mailing Address - Phone:270-783-0190
Mailing Address - Fax:
Practice Address - Street 1:615 SEVENTH AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101
Practice Address - Country:US
Practice Address - Phone:270-783-3573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36936208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64044571Medicaid
KYH53957Medicare UPIN