Provider Demographics
NPI:1346286184
Name:LOTTENBERG, LAWRENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:
Last Name:LOTTENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LAWRENCE
Other - Middle Name:
Other - Last Name:LOTTENBERG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1234 E DUPONT RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-7854
Mailing Address - Fax:260-458-5664
Practice Address - Street 1:11141 PARKVIEW PLAZA DR
Practice Address - Street 2:SUITE 305
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1713
Practice Address - Country:US
Practice Address - Phone:800-633-5331
Practice Address - Fax:260-266-2009
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME270082086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL039175100Medicaid
FL93798Medicare ID - Type Unspecified
93798UMedicare PIN
FL039175100Medicaid