Provider Demographics
NPI:1134781412
Name:LENTZ, JOSHUA DWAINE (MD)
Entity type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:DWAINE
Last Name:LENTZ
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 1:6810 STATE ROUTE 162 STE 215
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8566
Mailing Address - Country:US
Mailing Address - Phone:618-391-6495
Mailing Address - Fax:
Practice Address - Street 1:1212 BROADWAY
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249-1960
Practice Address - Country:US
Practice Address - Phone:618-651-0022
Practice Address - Fax:618-651-0023
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-08
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036158237207Q00000X
MI4301505964207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty