Provider Demographics
NPI:1255399978
Name:LORD, GUY R (MD)
Entity type:Individual
Prefix:
First Name:GUY
Middle Name:R
Last Name:LORD
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:PO BOX 639
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-0639
Mailing Address - Country:US
Mailing Address - Phone:262-512-9400
Mailing Address - Fax:
Practice Address - Street 1:1035 W GLEN OAKS LN
Practice Address - Street 2:SUITE 204
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3392
Practice Address - Country:US
Practice Address - Phone:262-512-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI210360202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30496000Medicaid
B54673Medicare UPIN
WI015330007Medicare ID - Type Unspecified