Provider Demographics
NPI:1184707952
Name:LOTT, VICKY M (MD)
Entity type:Individual
Prefix:
First Name:VICKY
Middle Name:M
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 1:623 SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843
Mailing Address - Country:US
Mailing Address - Phone:208-882-2011
Mailing Address - Fax:208-883-1853
Practice Address - Street 1:623 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843
Practice Address - Country:US
Practice Address - Phone:208-882-2011
Practice Address - Fax:208-883-1853
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8278207Q00000X
WAMD00040077207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1104639OtherDMERC
ID48264OtherBLUE CROSS
ID806323500OtherHEATHY CONNECTIONS
ID000010138246OtherREGENCE BLUESHIELD
ID806323500Medicaid
WA0159575OtherWA LABOR & INDUSTRIES
WA8298937Medicaid
IDH59812Medicare UPIN
ID000010138246OtherREGENCE BLUESHIELD
ID990015805Medicare ID - Type UnspecifiedID RR MEDICARE
WA0159575OtherWA LABOR & INDUSTRIES