Provider Demographics
NPI:1295725752
Name:GUYTON, LORI M (MD)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:M
Last Name:GUYTON
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 1:3301 LOGAN DR
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-3732
Mailing Address - Country:US
Mailing Address - Phone:618-993-0444
Mailing Address - Fax:618-998-9302
Practice Address - Street 1:3301 LOGAN DR
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3732
Practice Address - Country:US
Practice Address - Phone:618-993-0444
Practice Address - Fax:618-998-9302
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360946592084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036094659Medicaid
IL036094659Medicaid
ILK08550Medicare UPIN