Provider Demographics
NPI:1548395437
Name:WIVIOTT, LORY DAVID (MD)
Entity Type:Individual
Prefix:
First Name:LORY
Middle Name:DAVID
Last Name:WIVIOTT
Suffix:
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 1:54 MARTHA AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94131-2835
Mailing Address - Country:US
Mailing Address - Phone:415-469-0643
Mailing Address - Fax:
Practice Address - Street 1:2100 WEBSTER ST
Practice Address - Street 2:#404
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-2373
Practice Address - Country:US
Practice Address - Phone:415-923-3883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG0557430207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
E24834Medicare UPIN