Provider Demographics
NPI:1508893116
Name:LASSITER, HOMER LEON JR (MD)
Entity Type:Individual
Prefix:DR
First Name:HOMER
Middle Name:LEON
Last Name:LASSITER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6599
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36302-6599
Mailing Address - Country:US
Mailing Address - Phone:334-699-5994
Mailing Address - Fax:334-699-5995
Practice Address - Street 1:500 HEALTHWEST DRIVE
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303
Practice Address - Country:US
Practice Address - Phone:334-699-5994
Practice Address - Fax:334-699-5995
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL22263207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL150273Medicaid
AL009996800Medicaid
AL009996800Medicaid
AL105I085002Medicare PIN
ALE21428Medicare UPIN