Provider Demographics
NPI:1629294665
Name:LOTT, MARY E (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:E
Last Name:LOTT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:904-388-4646
Mailing Address - Fax:
Practice Address - Street 1:2606 PARK ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4520
Practice Address - Country:US
Practice Address - Phone:904-388-4646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME131370208000000X
GA0012652080H0002X
GA62137208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080H0002XAllopathic & Osteopathic PhysiciansPediatricsHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2665OtherEMPLOYER ID
FLPENDINGOtherMEDICARE
GA001265OtherRESIDENCY LICENSE
GA369518390EMedicaid
GA52319773OtherBCBS
GARES000Medicare UPIN