Provider Demographics
NPI:1639198179
Name:DOTSON, LORI JEAN (MD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:JEAN
Last Name:DOTSON
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 1:965 S BAILEY AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-6743
Mailing Address - Country:US
Mailing Address - Phone:269-639-2833
Mailing Address - Fax:269-639-2776
Practice Address - Street 1:965 S BAILEY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-6743
Practice Address - Country:US
Practice Address - Phone:269-639-2833
Practice Address - Fax:269-639-2776
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074647207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1417961137OtherBCBSM - BRONSON VICKSBURG OUTPATIENT CENTER
MI4100004 T10Medicaid
MI4574494Medicaid
MI1639198179Medicaid
MIF11053Medicare UPIN
MI4100004 T10Medicaid
MIC96065039Medicare PIN
MIC97618244 BV OUTPTMedicare PIN
MI1417961137OtherBCBSM - BRONSON VICKSBURG OUTPATIENT CENTER